Phone: 800-555-2546 Fax back to: 1-877-486-2621. Humana manages the pharmacy drug benefit for your patient. Certain requ
PRIOR AUTHORIZATION REQUEST FORM EOC ID: Administrative Product – Universal
Phone: 800-555-2546 Fax back to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. For Medicare Private-Fee-for-Service members, prior authorization is not required for Part-B-covered medications. The information below is needed for a Part B versus Part D determination for these members.
Patient name:
_______________________
Prescriber name: _______________________
Member/subscriber Number: _______________________
Fax: __________ Phone ______________
Date of Birth: _______________________
Office Contact:
Group number: Address:
_______________________
_______________________
_______________________ _________________________________ _________________________________ City, state ZIP:
_______________________
NPI: __________ Tax ID: Address:
______________
_______________________
City, state ZIP:
_______________________
Specialty / facility name (if applicable):
_________________________________ Drug name:
Expedited / Urgent By checking this box I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function.
Directions/SIG: Quantity:
Please attach pertinent medical history or information for this patient that may support approval. Please answer the following questions and sign. Q1. Please provide diagnosis: ___________________________________________________________ Q2. Please provide J-Code, if applicable: _____________________________________________________ Q3. Please provide ICD Diagnostic Codes: ___________________________________________________ Q4. Is this medication being requested for use in an ongoing investigational trial? Yes No Q3. Is this a reauthorization request? Yes No Q3. Please list therapeutic alternatives previously used with start/end dates and outcome:
This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for the return of this document. 483ALL0110 2010-10-07
