Prior Authorization Request Form - Health Partners Plans printable pdf download

HEALTH PARTNERS PLANS

PRIOR AUTHORIZATION REQUEST FORM

Abilify Maintena

Phone: 215-991-4300

Fax back to: 866-240-3712

Health Partners Plans manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician.

Please answer the following questions and fax this form to the number listed above.

PLEASE NOTE: Any information (patient, prescriber, drug, labs) left blank, illegible, or not attached WILL delay the review process.

Patient Name:

Prescriber Name:

Member Number:

Fax:

Phone:

Date of Birth:

Office Contact:

Address:

NPI:

State Lic ID:

City, State ZIP:

Address:

Primary Phone:

City, State ZIP:

Line of Business: □ Medicaid

□ CHIP

Specialty/facility name (if applicable):

□ Expedited/Urgent

Drug Name:

Strength:

Directions / SIG:

Please attach any pertinent medical history including labs and information for this member that may support approval.

Please answer the following questions and sign.

Q1. Has the patient tried and failed Risperdal® Consta® and Invega® Sustenna?



Yes



Q2. Is the member over the age of 18?



Yes



Q3. Does the member have a diagnosis of schizophrenia?



Yes

Q4. Has the patient been started on Abilify MaintenaTM while inpatient? Please provide discharge summary with date of

last injection.



Yes



Q5. Has the member tolerated treatment with oral Abilify® (aripiprazole) at a dose of 10 to 20 mg per day?



Yes



Q6. Does the patient have a history of long-term (greater than 3 months) non-compliance with oral antipsychotic

medication which would prevent the patient from using oral formulary atypical antipsychotic medication? Please submit

documentation.



Yes



Q7. Has the member failed measures (such as psychosocial interventions, psychoeducational interventions that have a

behavorial component and supportive services, and providing member with instructions and problem-solving strategies

such as reminders, self-monitoring tools, cues, and reinforcements) to improve compliance with formulary oral

medications? Please submit documentation.



Yes



Q8. Does the member have significant clinical decompensation, or is the member at high risk for decompensation and

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