Premera Blue Cross HMO
P.O. Box 327, MS 432
Seattle, WA 98111-0327
P.O. Box 327, MS 432
Seattle, WA 98111-0327
Pharmacy Services Prior Authorization Form
| Patient Name: | ID Number: | ||
| Date of Birth: | |||
| Prescriber's Name: | Office Contact: | ||
| Fax Number: | |||
| Prescriber's Address: | |||
| Prescriber's Signature: | Date: | Phone Number: | Ext.: |
Requested medication, strength and dosing schedule
| Name of the Drug: | |
| ICD Code: | Strength: |
| Diagnosis: | |
| Quantity/Month: | Dosing Schedule: |
Medications Tried
| Name | Strength | Dosing Schedule | Therapy Duration | Dates tried | Reason therapy stopped | |
| 1 | ||||||
| 2 | ||||||
| 3 | ||||||
| 4 | ||||||
| 5 |
Additional pertinent information
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|
| Please fax this back to Pharmacy Services | |
| Fax Number 1-888-260-9836 |
Phone Number 1-888-261-1756 |