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Dean Health Plan, Inc. a subsidiary of Premier Medical Insurance Group PO Box 56099 Madison, WI 53705 18002791301 6088281301 Fax: 6088274300 DRUG PRIOR AUTHORIZATION REQUEST Patient Name (please print)

How to fill out drug prior authorization request

How to fill out a drug prior authorization request:

1. Gather necessary information: Before starting the process, gather all the relevant information you will need to complete the drug prior authorization request. This may include details such as the patient's personal information, insurance information, prescribed medication information, and the reason why the medication requires prior authorization.
2. Download or obtain the required form: Check with your healthcare provider or insurance company to obtain the specific form needed for the drug prior authorization request. Some companies may have an online form that you can download and fill out electronically, while others may require you to request a physical copy.
3. Familiarize yourself with the form: Take the time to carefully read through the form and understand each section and the information required. This will help ensure that you provide all the necessary details and avoid any errors or omissions that could delay the authorization process.
4. Provide patient and insurance information: Begin by filling out the patient's personal information, including their full name, date of birth, address, and contact information. Additionally, provide the patient's insurance details, including the insurance company's name, policy number, and group number.
5. Include prescribing physician's information: Provide the name, contact information, and specialty of the prescribing physician. This information is crucial for the authorization process as it helps verify the medical necessity of the prescribed medication.
6. Provide medication details: List the name, strength, dosage instructions, and quantity of the medication that requires prior authorization. Include any additional pertinent information, such as the diagnosis or condition for which the medication is being prescribed.
7. Explain the medical necessity: In a separate section or field, provide a detailed explanation as to why the medication requires prior authorization. It is essential to articulate why alternative treatments or medications may not be suitable for the patient's particular condition, and why the requested medication is medically necessary.
8. Attach supporting documentation: Depending on the requirements of the prior authorization request, you may need to attach supporting documentation. This could include medical records, test results, or a letter of medical necessity from the prescribing physician. Make sure to review the form's instructions to determine which documents, if any, are necessary.
9. Review and submit the form: Before submitting the form, carefully review it for accuracy, ensuring all fields are filled out with the necessary information. Double-check the attached documentation, if any, to ensure it is complete and relevant. Once you are confident that everything is in order, submit the form according to the provided instructions. This may involve mailing it, faxing it, or uploading it to an online portal.

Who needs a drug prior authorization request?

1. Patients with specific insurance plans: Some insurance plans may require prior authorization for certain medications or treatments. It is common for plans to have a list of drugs that require this additional step before they will cover the cost.
2. Patients prescribed certain medications: Certain medications may be more likely to require prior authorization due to their cost, potential for abuse, or potential side effects. These medications may include specialty drugs, high-cost brand-name medications, or controlled substances.
3. Healthcare providers: Healthcare providers, including physicians, nurses, and pharmacists, often need to initiate the drug prior authorization request on behalf of their patients. They play a crucial role in providing the necessary information, filling out the form correctly, and submitting it to the appropriate channels.

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What is drug prior authorization request?

A drug prior authorization request is a process where healthcare providers must obtain approval from the insurance company before a drug can be prescribed to a patient.

Who is required to file drug prior authorization request?

Healthcare providers, such as doctors and pharmacists, are required to file a drug prior authorization request.

How to fill out drug prior authorization request?

Healthcare providers must complete the necessary forms provided by the insurance company and submit relevant medical documentation.

What is the purpose of drug prior authorization request?

The purpose of a drug prior authorization request is to ensure that the prescribed drug is necessary and appropriate for the patient's condition.

What information must be reported on drug prior authorization request?

The drug name, dosage, prescribing provider, patient information, medical diagnosis, and rationale for prescribing the drug must be reported on a drug prior authorization request.