UPMC Health Plan Saphris PA Form 2011-2025 free printable template

New medication Ongoing medication Diagnosis If ongoing provide date started If medication is ongoing Did member Show improvement while on therapy Date of diagnosis Yes No Medical History Has the member tried and failed an antipsychotic Please list antipsychotic medications Dates of therapy Yes No Reason for discontinuation Please list other medications used to treat the above condition Medication Trial/ Previous Therapy Start Date End Date List Adverse Reactions/Side Effects/ Please...

How to fill out upmc prior authorization form

How to fill out UPMC Health Plan Saphris PA Form

1. Obtain the UPMC Health Plan Saphris PA Form from the official website or healthcare provider.
2. Fill in the patient's personal information at the top of the form, including name, date of birth, and insurance information.
3. Provide details about the diagnosis, including the relevant ICD-10 codes.
4. Document previous treatments and medications tried, noting the durations and responses to each.
5. Include the requested dosage and treatment plan for Saphris, along with the intended duration of therapy.
6. If applicable, attach any additional supporting documents such as lab results or clinical notes.
7. Sign and date the form, ensuring that all required signatures are included.
8. Submit the completed form to the appropriate insurance review department as instructed.

Who needs UPMC Health Plan Saphris PA Form?

1. Patients who are prescribed Saphris and have UPMC Health Plan coverage may need this form for prior authorization.
2. Healthcare providers who are prescribing Saphris on behalf of their patients to initiate the insurance approval process.

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What is UPMC Health Plan Saphris PA Form?

The UPMC Health Plan Saphris PA Form is a prior authorization request form used to obtain approval for the medication Saphris from UPMC Health Plan.

Who is required to file UPMC Health Plan Saphris PA Form?

Healthcare providers, such as physicians or prescribers, are required to file the UPMC Health Plan Saphris PA Form on behalf of their patients to obtain medication approval.

How to fill out UPMC Health Plan Saphris PA Form?

To fill out the UPMC Health Plan Saphris PA Form, you need to provide patient information, including demographics and insurance details, as well as the prescriber’s information, the diagnosis, and relevant clinical information justifying the need for the medication.

What is the purpose of UPMC Health Plan Saphris PA Form?

The purpose of the UPMC Health Plan Saphris PA Form is to ensure that the prescribed medication is medically necessary and meets the criteria for coverage under the patient's health plan.

What information must be reported on UPMC Health Plan Saphris PA Form?

The information that must be reported includes the patient's name, date of birth, insurance details, prescriber's information, diagnosis code, treatment history, and any relevant clinical notes supporting the use of Saphris.