Medicare.healthpartnersplans.com

HEALTH PARTNERS MEDICARE
PRIOR AUTHORIZATION REQUEST FORM
Phone: 215-991-4300 Fax back to: 866-371-3239
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 left blank or illegible may delay the
review process.
Patient Name:
Prescriber Name:
Expedited/Urgent Drug Name and Strength: Please attach any pertinent medical history or information for this member that may support approval. Please answer the
following questions and sign.
Q1. What is the requested duration of therapy? Q2. Has the member tried and failed Risperdal® Consta®? Q4. Does the member have a diagnosis of schizophrenia? Q5. Has the member tolerated treatment with oral Abilify® (aripiprazole) at a dose of 10 to 20 mg per day? Q6. Does the member have a history of long-term (greater than 3 months) non-compliance with oral antipsychotic medication? Q7. Does the member have significant clinical decompensation, or is the member at high risk for decompensation and functional impairment (ie. increased amount of hospitalizations, safety risk)? Please submit documentation. Q8. 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. Q9. Does the member have a documented medical reason, such as treatment failure at maximum doses, intolerable side 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 to arrange for the return of this document Page 1 of 2
HEALTH PARTNERS MEDICARE
PRIOR AUTHORIZATION REQUEST FORM
Phone: 215-991-4300 Fax back to: 866-371-3239
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 left blank or illegible may delay the
review process.
Patient Name:
Prescriber Name:
effects, or potential drug interactions, which would prevent the member from using oral formulary atypical antipsychotic medication? Please submit documentation. ___________________________________________________________ _________________________________________ 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 to arrange for the return of this document Page 2 of 2

Source: http://medicare.healthpartnersplans.com/media/100005059/Abilify-Initial-Medicare-2014.pdf