Health Net - Prior Authorization / Formulary Exception Request Fax Form

Prior Authorization / Formulary Exception Request Fax Form

FAX TO: (800) 977-8226

Form must be fully completed to avoid a processing delay.

For status of a request, call: (800) 867-6564

Patient’s Name (Last, First, MI)

Date of Birth ------------------- MM / DD / YYYY -------------------

/

/

Member ID # ------------ Please print clearly and enter one digit per box -------------

Patient’s Phone ----------- Please print clearly and enter one digit per box -----------

(

)

–

Patient’s Address, City, State, Zip

Gender

Allergies

M

F

Provider’s Name (Last, First, MI)

Provider Specialty

Contact Name

Provider’s Address, City, State, Zip

NPI #

------- Provider’s Phone ----- Please print clearly and enter one digit per box -------

-------- Provider’s Fax ------- Please print clearly and enter one digit per box --------

(

)

(

)

–

–

Medication Name and Strength

Quantity

Direction for Use and Duration

Administered:

Doctor’s Office

Dialysis Center

Home Health

By Patient

Other (specify):

Diagnosis

ICD Code

New Start with This Medication:

Yes

No

If No, Date of First Dose

Medications Previously Tried with Dates of Use

Medical Justification and Supporting Information (attach labs and/or chart notes as appropriate)

For Commercial members for injectable drugs only:

Are you the patient’s primary care physician?

Yes

No

Has the patient provided an authorized referral?

Yes

No

Utilization Management Authorization # (attach copy):

The patient will obtain the medication from: The Provider

A Pharmacy

For Medicare members only: Please review carefully and complete each applicable subsection.

For all requests: Is the patient currently receiving dialysis?

Yes

No

For drugs considered to be High Risk Medications (HRM) for the elderly (i.e. drugs on Yes

Comment:

the Beers List), is the patient continuing on this medication without adverse effects?

No

For immunosuppressive medication requests:

If Yes, Date

Is it being used for a transplant? Yes

No

of transplant:

For antiemetic medication requests:

Will this drug be used as full therapeutic replacement for intravenous antiemetic

Will the patient be on any other concurrent antiemetic therapy? Yes

No

drugs within 2 hours and continued for a period not to exceed 48 hours of

Specify drug(s) & route: _______________________________________________

chemotherapy?

Yes

No

For nutritional supplement (enteral or parenteral) medication requests: Does the patient have a G-tube?

Yes

No

Does the patient have a permanent dysfunction of the digestive track?

Yes

No

I certify that the above information is correct to the best of my knowledge.

Physician’s Signature

Date

Name of provider/vendor submitting this form if other than the prescriber above

Phone #

The documents accompanying this facsimile transmission may contain information that is confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified

that any disclosure, copying, distribution or use of the information contained in this transmission is strictly prohibited. If you have received this transmission in error, please notify the sender

immediately by telephone or by return FAX and destroy this transmission, along with any attachments.

Mailing Address: HNPS Prior Authorization Department, 10540 White Rock Road #280, Rancho Cordova, CA 95670

For copies of prior authorization forms and guidelines, please call (800) 867-6564 or visit the provider portal at

Revised 08-2015