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The completed form is faxed to the number listed on the cover for Humana-managed reviews requiring additional clinical information.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information is needed to support a prior authorization request?",{"text":68,"@type":64},"The form requests patient/member identifiers, diagnosis, J-code (if applicable), ICD diagnostic codes, therapeutic alternatives with outcomes, relevant lab values, dosing rationale, and the patient’s complete current medication list.",{"name":70,"@type":61,"acceptedAnswer":71},"How is an expedited or urgent request indicated?",{"text":72,"@type":64},"Check the expedited/exigent/urgent box and certify that the member’s condition may seriously jeopardize life or ability to regain maximum function, including an explanation of exigency.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283963,1791252950,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":55,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","PRIOR AUTHORIZATION REQUEST FORMEOC ID:  \nAdmin-State Specific Authorization Form 1SS  \nPhone: 1-800-555-2546 Fax back to: 1-877-486-2621  \nHumana manages the pharmacy drug benefit for your patient named below. Certain requests for coverage require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.  \nPlease reference Humana’s coverage policy at [https://apps.humana.com/tad/tad_new/home.aspx?type=provider](https://apps.humana.com/tad/tad_new/home.aspx?type=provider) for all clinical criteria.  \nNote: This fax form is for requests for a member/resident in accordance with state mandates.  \n\n| Patient name: | Prescriber name: |  |\n| --- | --- | --- |\n| Member/subscriber number: | Fax: | Phone: |\n| Patient date of birth: Group | Office contact: |  |\n| number: | NPI: | Tax ID: |\n| Address: | Address: |  |\n| City, state, ZIP: | City, state, ZIP:\u003Cbr>Specialty/facility | name (if applicable): |\n\n(Note: All reviews will be processed with generic equivalents for brand drugs whenever possible. )  \nPlease attach any pertinent medical history or information for this patient that may support approval. Provide the following information, sign this form and return it.  \n􀀃 Expedited/exigent/urgent  \nBy checking this box, I certify an expedited/exigent/urgent review is required. The member has a health condition that may seriously jeopardize his/her life or ability to regain maximum function. Please include explanation of exigency    \n\n| J-code (if applicable) | Drug name | Dose | Directions for use |  |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| Q1 . Please provide diagnosis: * |  |  |  |  |\n| Q2 . Please provide J-code, if applicable: |  |  |  |  |\n| Q3 . Please provide ICD Diagnostic Codes: |  |  |  |  |\n| Q4 . Is the drug being requested for use in an ongoing investigational trial (please provide trial name and registration number)? |  |  |  |  |\n\nHeight: Weight: Allergies:  \n75906ALL0922-D  \nPRIOR AUTHORIZATION REQUEST FORMEOC ID:  \nAdmin-State Specific Authorization Form 1SS  \nPhone: 1-800-555-2546 Fax back to: 1-877-486-2621  \n\n| Patient Name: | Prescriber Name: |\n| --- | --- |\n\n\n|  Yes  No |\n| --- |\n| Q5 . Please provide location of treatment (e.g. MD office, facility, home health) including name and Tax ID\\#: |\n| Q6 . Is the request for a reauthorization?\u003Cbr> Yes  No |\n| Q7 . Is the patient currently stable on therapy?\u003Cbr> Yes  No |\n| Q8 . Please list all therapeutic alternatives previously used with start/end dates and outcome: |\n| Q9 . Please provide all relevant lab values related to the patient's medical conditions: |\n| Q10 . If the request is for duplicate therapy for the patient’s health condition, please provide information and rationale for concomitant use of the medications: |\n| Q11 . Please provide dosing rationale for the requested quantity: |\n| Q12 . Please provide patient's complete current medication list: |\n| Q13 . Please provide all pertinent medical information related to the patient's diagnosis: |\n| Q14 . Please include any additional comments that would be of benefit to the review of this request: |\n\nPrescriber signature Date  \nI declare under penalty of perjury under the laws of the United States of America that the information provided is true and correct. This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reference to the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately t","cbCaijY51R3b8uAk","https://ap.wps.com/l/cbCaijY51R3b8uAk","pdf",138151,"English","# Patient and Prescriber Information\n## Submission Instructions and Notes\n# Clinical and Drug Details\n## Expedited/Urgent Review (If Applicable)\n## Drug, J-code, Dose, Directions\n## Diagnosis and Coding Questions\n# Treatment and Supporting Information\n## Treatment Location\n## Reauthorization and Stability\n## Alternatives, Labs, and Medication Rationale\n## Dosing Rationale and Current Medication List\n# Signature and Attestation","[{\"question\":\"Who completes this form and where should it be sent?\",\"answer\":\"The prescriber provides the required information. The completed form is faxed to the number listed on the cover for Humana-managed reviews requiring additional clinical information.\"},{\"question\":\"What information is needed to support a prior authorization request?\",\"answer\":\"The form requests patient/member identifiers, diagnosis, J-code (if applicable), ICD diagnostic codes, therapeutic alternatives with outcomes, relevant lab values, dosing rationale, and the patient’s complete current medication list.\"},{\"question\":\"How is an expedited or urgent request indicated?\",\"answer\":\"Check the expedited/exigent/urgent box and certify that the member’s condition may seriously jeopardize life or ability to regain maximum function, including an explanation of exigency.\"}]","State-specific prior authorization request form | PDF",1789623580]