Prior Authorization Form

Prior Authorization Form Atypical Antipsychotics

Access this PA form at https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_Atypical_Antypsychotics_PA_Request_Form.pdf If the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.

Member Information LAST NAME:

FIRST NAME:

ID NUMBER:

DATE OF BIRTH: –

–

Prescriber Information LAST NAME:

FIRST NAME:

NPI NUMBER:

DEA NUMBER:

PHONE NUMBER:

FAX NUMBER: –

–

–

Is the prescriber a TennCare provider with a Medicaid ID?

Yes

No

Is the prescriber a single-patient contract holder for this patient?

Yes

No

–

Requested Atypical Antipsychotic Preferred aripiprazole ODT (generic for

Abilify®

Discmelt®)

quetiapine (generic for

aripiprazole solution (generic for Abilify®)

risperidone ODT (generic for Risperdal® M-tab®)

aripiprazole tablets (generic for Abilify®)

risperidone solution (generic for Risperdal®)

clozapine (generic for Clozaril®)

risperidone tablets (generic for Risperdal®)

Latuda®

Saphris®

olanzapine (generic for

Zyprexa®)

STRENGTH:

Zydis®)

ziprasidone (generic for Geodon®)

DIRECTIONS:

QUANTITY:

DURATION:

****Do not include documentation that is not requested on this form****

Clinical Criteria Documentation What is the diagnosis for this medication? Agitation of Dementia

Psychotic Disorder

Severe Tic Disorder/Tourettes Syndrome

Aggression/Impulse Control Disorder

Schizophrenia/Schizoaffective Disorder

Substance-induced psychotic disorder

Bipolar Disorder

Severe refractory depression

Delusional Disorder

Severe refractory OCD

Psychotic depression

Severe refractory PTSD

Other:

2.

Please provide an ICD-10 Code for the Diagnosis:

3.

Has a preferred atypical antipsychotic been used in the past? IF YES, which medication?

Dose:

Duration:

Reason for discontinuation:

4.

SPECIFY: __________________________

Seroquel® XR

olanzapine ODT (generic for Zyprexa

1.

Non-Preferred Seroquel®)

Yes

No

Frequency:

Does patient have documented noncompliance to oral atypicals, or non-response due to non-compliance?

Continued on next page. Signature MUST be submitted on page 2.

This facsimile transmission contains legally privileged and confidential information intended for the parties identified below. If you have received this transmission in error, please immediately notify us by telephone and return the original message to TennCare Pharmacy Program, c/o Magellan Health Services, 1st Floor South, 14100 Magellan Plaza, Maryland Heights, MO 63043. Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.

© 2016, Magellan Health Services. All Rights Reserved. Revision History: 07/01/2016

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Yes

No

Prior Authorization Form Atypical Antipsychotics

Access this PA form at https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_Atypical_Antypsychotics_PA_Request_Form.pdf PATIENT NAME:

DATE OF BIRTH: –

5.

6.

– Yes

Has the patient been on another atypical antipsychotic within the last 30 days? IF YES, has this medication been discontinued?

Yes

No (provide reason)

Is the patient also taking antidepressants?

Yes

No

No

IF YES, list the medication(s):

7.

Is the patient unable to swallow or unable to absorb oral medications?

Yes

No

* For patients with and Intellectual or Developmental Disability, the I/DD PA worksheet MUST accompany this form. Please note any other information pertinent to this PA request:

Prescriber Signature (Required)

Date

(By signature, the Physician confirms the above information is accurate and verifiable by patient records.)

Fax This Form to: 1-866-434-5523 Mail requests to: TennCare Pharmacy Program c/o Magellan Health Services 1st floor South, 14100 Magellan Plaza Maryland Heights, MO 63043 Phone: 1-866-434-5524

Magellan Health Services will provide a response within 24 hours upon receipt.

© 2016, Magellan Health Services. All Rights Reserved.

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