Get the free Specialty Drug Prior Authorization Criteria Library - Paramount

Criteria: P0198 Approved: 11/2014 Reviewed:Prior Authorization Criteria Form This form applies to Paramount Advantage and Paramount Commercial Members OnlyTikosyn Complete/review information, sign

How to fill out specialty drug prior authorization

How to fill out specialty drug prior authorization

1. To fill out a specialty drug prior authorization, follow these steps:
2. Gather all necessary information such as patient details, prescribing physician information, drug name, dosage, and specific medical indication for the specialty drug.
3. Contact the insurance company or pharmacy benefit manager (PBM) to obtain the appropriate prior authorization forms.
4. Fill out the forms accurately, providing all requested information.
5. Include any supporting documentation such as medical records, lab results, or clinical notes that justify the need for the specialty drug.
6. Double-check the completed forms for any errors or missing information before submitting them.
7. Submit the filled-out forms and supporting documentation to the insurance company or PBM via fax, electronic submission, or mail.
8. Keep a copy of the submitted forms and supporting documentation for your records.
9. Follow up with the insurance company or PBM to ensure the prior authorization request is being processed and to address any additional requirements or questions.
10. Await the decision on the prior authorization request. It may take some time for the insurance company or PBM to review the request and make a determination.
11. If the prior authorization is approved, you can proceed with obtaining the specialty drug. If it is denied, you may need to explore alternative treatment options or appeal the decision.
12. Note: The specific process and requirements for filling out a specialty drug prior authorization may vary depending on the insurance company, PBM, and specific drug being requested. It's always best to consult the insurance company or PBM for the most up-to-date instructions and forms.

Who needs specialty drug prior authorization?

1. Specialty drug prior authorization is typically required for individuals who need to access high-cost or high-risk medications known as specialty drugs.
2. This authorization process ensures that the drug is being used appropriately and that there is a medical necessity for its use.
3. Patients who have complex medical conditions or require specialized treatments often fall under the category of needing specialty drugs and, consequently, prior authorization.
4. Insurance companies and pharmacy benefit managers (PBMs) evaluate the prior authorization requests based on medical criteria, cost-effectiveness, and their formulary guidelines to determine the coverage of specialty drugs.
5. It is important to note that the specific criteria for requiring specialty drug prior authorization may vary depending on the insurance plan or PBM.

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