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

Evzio

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 Evzio.

Drug Name (select from list of drugs shown)

Evzio (naloxone)

Other, Please specify

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.

Does the patient require emergency treatment of known or suspected

opioid overdose, as manifested by respiratory and/or central nervous

system depression; intended for immediate administration as emergency

therapy in settings where opioids may be present?

[If no, then no further questions.]

Has the patient had a documented therapeutic failure of Narcan Nasal

Spray OR naloxone 2 mg/2 mL injection (off-label intranasal use)?

[Note: Documentation MUST include paid claims AND chart documentation from the provider supporting

contraindication to preferred alternatives.]

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