CA SFHP Universal Pharmacy Prior Authorization free printable template

Universal Pharmacy Prior Authorization Form Confidential Information Patient Name Patient ID NumberPrescriber NameSpecialtyPrescriber Phone () Prescriber AddressPrescriber Fax ()City NPI×StatePharmacy

How to fill out CA SFHP Universal Pharmacy Prior Authorization

How to fill out CA SFHP Universal Pharmacy Prior Authorization Form

1. Obtain the CA SFHP Universal Pharmacy Prior Authorization Form from the California San Francisco Health Plan website or your pharmacy.
2. Fill in the patient’s information including name, date of birth, and insurance details.
3. Provide the prescribing physician’s information, including their name, contact number, and NPI (National Provider Identifier).
4. Indicate the medication that requires prior authorization, including the name, dosage, and quantity.
5. Specify the diagnosis and any related medical conditions that justify the need for the medication.
6. Attach any relevant clinical documentation or notes from the physician to support the request.
7. Review the completed form for accuracy and completeness.
8. Submit the form to the appropriate pharmacy benefits management (PBM) or insurance provider via fax or online submission.

Who needs CA SFHP Universal Pharmacy Prior Authorization Form?

1. Patients who require medication that is not on the formulary or is subject to additional restrictions under their health plan.
2. Healthcare providers and pharmacists who need to obtain prior authorization for specific medications before dispensing.

People Also Ask about

How do I submit a prior authorization to Optum?

Submitting a PA request to OptumRx via phone or fax above. For urgent requests, please call us at 1-800-711-4555. (Hours: 5am PST to 10pm PST, Monday through Friday.)

What is the fax number for Optum RX appeals?

Please have the doctor or a qualified member of the office staff complete the next page(s) and fax the completed form to 1-844-403-1024. If you have questions or want to speak with an Optum Rx Prior Authorization Advocate, call 1-800-711-4555.

What is the fax number for Optum RX prior authorization?

Fax this form to: 1-866-434-5523 Phone: 1-866-434-5524 OptumRx will provide a response within 24 hours upon receipt.

How do I fax a prescription to OptumRx?

Fax 1-800-491-7997 – Send a complete prescription using the Physician Fax Form.

What is the fax number for Express Scripts prior authorization?

Your doctor can initiate the prior authorization process by calling Express Scripts toll-free at 800‑417‑8164 or by fax at 800‑357‑9577.

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What is CA SFHP Universal Pharmacy Prior Authorization Form?

The CA SFHP Universal Pharmacy Prior Authorization Form is a document required by the San Francisco Health Plan (SFHP) to obtain approval for certain medications before they can be dispensed. This form helps ensure that prescribed medications are medically necessary and covered under the patient's health plan.

Who is required to file CA SFHP Universal Pharmacy Prior Authorization Form?

Healthcare providers prescribing specific medications that require prior authorization from SFHP are required to file the CA SFHP Universal Pharmacy Prior Authorization Form on behalf of their patients.

How to fill out CA SFHP Universal Pharmacy Prior Authorization Form?

To fill out the CA SFHP Universal Pharmacy Prior Authorization Form, healthcare providers need to complete sections detailing the patient's information, the prescribing physician's information, the medication requested, the diagnosis, and any relevant clinical information that supports the need for the medication.

What is the purpose of CA SFHP Universal Pharmacy Prior Authorization Form?

The purpose of the CA SFHP Universal Pharmacy Prior Authorization Form is to ensure that medications prescribed to patients are medically appropriate and to manage healthcare costs by requiring prior review and approval for specific drugs before they are allowed to be dispensed.

What information must be reported on CA SFHP Universal Pharmacy Prior Authorization Form?

The information that must be reported on the CA SFHP Universal Pharmacy Prior Authorization Form includes patient details (name, date of birth, member ID), provider information (name, contact details), prescribed medication (name, dosage, quantity), clinical diagnosis, and any supporting documentation that justifies the necessity of the medication.