Prior Authorization Criteria Form - Passport Health Plan printable pdf download

Prior Authorization Criteria Form - Passport Health Plan

Prior Authorization Form

PASSPORT HEALTH PLAN KENTUCKY MEDICAID

Movantik

This fax machine is located in a secure location as required by HIPAA regulations.

Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-844-802-1406.

Please contact CVS/Caremark at 1-844-380-8831 with questions regarding the prior authorization process.

When conditions are met, we will authorize the coverage of Movantik.

Drug Name (select from list of drugs shown)

Movantik Tablets (naloxegol)

Quantity

Frequency

Strength

Route of Administration

Expected Length of Therapy

Patient Information

Patient Name:

Patient ID:

Patient Group No.:

Patient DOB:

Patient Phone:

Prescribing Physician

Physician Name:

Physician Phone:

Physician Fax:

Physician Address:

City, State, Zip:

Diagnosis:

ICD Code:

Comments:

Please circle the appropriate answer for each question.

Is the patient 18 years of age or older?

[If no, then no further questions.]

Does the patient have a documented diagnosis of opioid induced

constipation?

[If no, then no further questions.]

Does the patient have chronic non-cancer pain?

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (Or Authorized) Signature and Date

Prior Authorization Criteria Form - Passport Health Plan