MD Vivitrol/Campral Prior Authorization 2018-2025 free printable template

Maryland Medicaid Pharmacy Program Vivitrol / Campral Prior Authorization Form Fax 866 440-9345 Phone 800 932-3918 Patient s Information Date Participant s Maryland Medicaid Number Prescriber s Information Phone Fax Contact Person for this Request Medication Strength Quantity Refills Directions for Use Check each box below that applies for the requested medication. Please Note For the initial prescription a participant will be allowed a 90 day supply original 2 refills to allow for...

How to fill out MD VivitrolCampral Prior Authorization

How to fill out MD Vivitrol/Campral Prior Authorization

1. Obtain the MD Vivitrol/Campral Prior Authorization form from the appropriate healthcare provider or insurance company.
2. Fill out the patient's personal information, including name, date of birth, and insurance details.
3. Indicate the diagnosis and reason for the requested medication Vivitrol or Campral.
4. Include any relevant clinical information or medical history that supports the need for the medication.
5. Provide information about previous treatments and responses to those treatments.
6. Review all entries for accuracy and completeness.
7. Sign and date the form where required.
8. Submit the completed form to the designated insurance contact or fax number.
9. Follow up with the insurance company to confirm receipt and check on the status of the authorization.

Who needs MD Vivitrol/Campral Prior Authorization?

1. Individuals who have a diagnosis of alcohol dependence and are seeking treatment with Vivitrol.
2. Patients diagnosed with opioid dependence who are candidates for Vivitrol.
3. Individuals who require Campral as part of their treatment plan for alcohol dependence.
4. Those who are covered by an insurance plan that requires prior authorization for the use of these medications.

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What is MD VivitrolCampral Prior Authorization?

MD VivitrolCampral Prior Authorization is a process that requires healthcare providers to obtain approval from insurance companies before prescribing medications such as Vivitrol and Campral, which are used for the treatment of substance use disorders.

Who is required to file MD VivitrolCampral Prior Authorization?

Healthcare providers, such as doctors or prescribing clinicians, are required to file MD VivitrolCampral Prior Authorization on behalf of their patients who need these medications.

How to fill out MD VivitrolCampral Prior Authorization?

To fill out MD VivitrolCampral Prior Authorization, providers must complete the designated authorization form provided by the insurance company, including patient information, medication details, medical history, and treatment plan.

What is the purpose of MD VivitrolCampral Prior Authorization?

The purpose of MD VivitrolCampral Prior Authorization is to ensure that the prescribed medications are medically necessary and appropriate for the patient's condition, while also controlling costs for insurers.

What information must be reported on MD VivitrolCampral Prior Authorization?

The information that must be reported includes patient demographics, diagnosis, medication details, previous treatments, and the rationale for using Vivitrol or Campral in the specific case.