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PRIOR AUTHORIZATION REQUEST FORM

BMCHPQHP Standard Form

Massachusetts Standard Form for Medication Prior Authorization Requests

Phone: 888-566-0008 Fax back to: 866-305-5739

ENVISION RX OPTIONS 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 left blank or illegible may

delay the review process.

Patient Name: Prescriber Name:

This transmission may contain protected health information, which is transmitted pursuant to an authorization or as permitted by law. The information herein is confidential and

intended only for use by the designated recipient who/which must maintain its confidentiality and security. If you are not the designated recipient, you are strictly prohibited from

disclosing, copying, distributing, or taking action in reliance on the contents hereof. If you have received this transmission in error, please notify the sender immediately and

arrange for the return or destruction of all of its contents. Unauthorized redisclosure of confidential health information is prohibited by state and federal law.

Member/Subscriber Number: Fax: Phone:

Date of Birth: Office Contact:

Group Number: NPI: State Lic ID:

Address: Address:

City, State ZIP: City, State ZIP:

Primary Phone: Specialty/facility name (if applicable):

Expedited/Urgent

Drug Name and Strength:

Directions / SIG:

Please attach any pertinent medical history or information for this patient that may support approval. Please answer the

following questions and sign.

Q1. Is this request for initial or continuation of therapy?

Initial Continuing Therapy

Q2. If Continuing therapy, what date was the therapy initiated? (MM/YY)

Q3. What is the primary diagnosis related to the medication request?

Q4. What is the reason for the request?

Prior Authorization, Step Therapy, Formulary Exception

Quantity Exception

Specialty Drug

Other

Q5. If OTHER, please describe.

PRIOR AUTHORIZATION REQUEST FORM

BMCHP BMCHPQHP Standard Form

Massachusetts Standard Form for Medication Prior Authorization Requests

Phone: 888-566-0008 Fax back to: 866-305-5739

ENVISION RX OPTIONS 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 left blank or illegible may

delay the review process.

Patient Name: Prescriber Name:

This transmission may contain protected health information, which is transmitted pursuant to an authorization or as permitted by law. The information herein is confidential and

intended only for use by the designated recipient who/which must maintain its confidentiality and security. If you are not the designated recipient, you are strictly prohibited from

disclosing, copying, distributing, or taking action in reliance on the contents hereof. If you have received this transmission in error, please notify the sender immediately and

arrange for the return or destruction of all of its contents. Unauthorized redisclosure of confidential health information is prohibited by state and federal law.

Q6. What is the date the therapy will be initiated?

Q7. Is there a dispense as written specification?

Yes No

Q8. If YES, please indicate the rationale.

Q9. Is the medication a compound?

Yes No

Q10. If it is a compound, please list the ingredients:

Q11. For compound or off label use, please include citation to peer reviewed literature.

Q12. Please list any pertinent comorbidities.

Q13. Please list the patient's Height and Weight.

Q14. Please list any concurrent medications.

Q15. Which of the following opioid management tools are in place:

Risk assessment

Treatment Plan

Informed Consent

Pain Contract

Pharmacy/Prescriber Restriction

Q16. Please list any therapies that have been tried/failed.

PRIOR AUTHORIZATION REQUEST FORM

BMCHP BMCHPQHP Standard Form

Massachusetts Standard Form for Medication Prior Authorization Requests

Phone: 888-566-0008 Fax back to: 866-305-5739

ENVISION RX OPTIONS 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 left blank or illegible may

delay the review process.

Patient Name: Prescriber Name:

This transmission may contain protected health information, which is transmitted pursuant to an authorization or as permitted by law. The information herein is confidential and

intended only for use by the designated recipient who/which must maintain its confidentiality and security. If you are not the designated recipient, you are strictly prohibited from

disclosing, copying, distributing, or taking action in reliance on the contents hereof. If you have received this transmission in error, please notify the sender immediately and

arrange for the return or destruction of all of its contents. Unauthorized redisclosure of confidential health information is prohibited by state and federal law.

Q17. Does the patient have contraindications to any alternative therapies?

Yes No

Q18. If yes, please describe.

Q19. Were any nonpharmacologic therapies tried?

Yes No

Q20. If yes, please describe.

Q21. Please list any relevant lab values.

Q22. If continuing therapy, has the patient shown improvement in related condition while on therapy?

Yes No

Q23. Please provide the following information if the prescribers office will be supplying the medication to the patient

(Buy and Bill): J-Codes:___________________ Procedure codes(s) for administration:___________________

Number of units and visits:______________Date of planned adminstration:___________

___________________________________________________________ _________________________________________

Prescriber Signature Date