Microsoft word - pharmacy general form 2-07.doc

Pharmacy Pre-authorization Request Form
*Note: Please use specific forms available on the provider website when prescribing the following drugs:
Proton Pump Inhibitors (i.e. Aciphex, Nexium, omeprazole, Prevacid, Protonix), Non-sedating antihistamines (i.e. Allegra, Clarinex, Zyrtec, incl.
Singulair), Celebrex, Statins (i.e. Lipitor, Vytorin) and Infertility Treatments
Date: _______________________________________ Physician Name: _________________________________
Member Name: _______________________________ Physician Specialty: ______________________________ Member ID Number: ___________________________ Physician Address: _______________________________ Member Age: ________________________________ Physician Telephone: _____________________________ Fax/E-mail: ____________________________ Please provide all requested information. Incomplete forms will be returned for additional information. Medication requested: __________________________________________________________________________ Dose/expected duration of treatment: ______________________________________________________________ Diagnosis: ___________________________________________________________________________________ Reason for request (please be as specific as possible): _________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Other medications used to treat condition and dates used: ______________________________________________ ____________________________________________________________________________________________ For ConnectiCare Use Only:
Approved/denied (circle one) by: ______________________________Approval expiration date*: ____________ Comments: __________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ *If the physician wishes to request further continuation of the pre-authorization for a period of time that exceeds the approved expiration date, the physician will need to supply clinical information to support the need. Authorizations are not given for >1 year. If required, submit an extension request prior to the end of the authorization period. ConnectiCare Pharmacy Services: fax - (860) 674-2851, or e-mail - pharmacy@connecticare.com
To speak to a Medical Director or Pharmacist regarding a pre-authorization decision, call 1-800-828-3407.
This is confidential information. If you receive this form in error, please notify Provider Services at 1-800-828-3407

Source: http://www.synvisconehcp.com/media/pdf/ConnectiCareVSPAForm.pdf