Prescription Prior Authorization Request Form

Is this request for initial or continuing therapy? If continuing therapy, provide treatment start date

Allergic reaction Drug-to-drug interaction Please describe reaction:

Previous episode of an unacceptable side effect or therapeutic failure
Please provide clinical information:

Clinical contraindication, co-morbidity, or unique patient circumstance as a contraindication to a preferred drug.
Please provide clinical information:

Age specific indications.
Please provide patient age and explain:

Unique clinical indication supported by FDA approval or peer reviewed literature.
Please explain and provide a reference:

Unacceptable clinical risk associated with therapeutic change.
Additional information required:

Client is under a Conditional Discharge or Outpatient Treatment Order and is psychiatrically stable on this medication.

Client discharged from inpatient psychiatric unit within the past 30 days and is psychiatrically stable on this medication.

Client is receiving ACT services and is psychiatrically stable on this medication.

Other. Please explain:

Please attach or provide any pertinent medical information that should be considered including labs when appropriate.

- Attachment Type:
- Select a file to upload:
- Attachments are optional. If needed you can upload and attach files to this request.
  The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .xlsx, .ppt, .txt"
  Files must be 3 MB (3,000,000 bytes) or less.

I certify that the information provided is accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to civil or criminal liability.

PRESCRIBER'S SIGNATURE:

DATE:

Prescriber's Printed Name:

Phone Number:

Contact Person for Scheduling of Peer-to-Peer:

Phone Number:

AmeriHealth Caritas/PerformRx Fax: 1-855-839-3883

NH Healthy Families/Envolve Fax: 1-866-399-0929

Well Sense Health Plan/EnvisionRX Fax: 1-866-305-5739

Revision Date: 09/03/2019

New Hampshire Medicaid - Managed Care Organization (MCO)
Community Mental Health Center
Prior Authorization/Mental Health Drug Approval Form

CHAPTER 188 OF THE LAWS OF 2004 REQUIRES THAT MEDICAID ONLY COVER NON-PREDERRED DRUGS UPON A FINDING OF MEDICAL NECESSITY BY THE PRESCRIBING PHYSICIAN. CHAPTER 188 REQUIRES THAT YOU BASE YOUR DETERMINATION OF MEDICAL ON THE FOLLOWING CRITERIA.

New Hampshire Medicaid - Managed Care Organization (MCO) Community Mental Health Center Prior Authorization/Mental Health Drug Approval Form

CHAPTER 188 OF THE LAWS OF 2004 REQUIRES THAT MEDICAID ONLY COVER NON-PREDERRED DRUGS UPON A FINDING OF MEDICAL NECESSITY BY THE PRESCRIBING PHYSICIAN. CHAPTER 188 REQUIRES THAT YOU BASE YOUR DETERMINATION OF MEDICAL ON THE FOLLOWING CRITERIA.

New Hampshire Medicaid - Managed Care Organization (MCO)
Community Mental Health Center
Prior Authorization/Mental Health Drug Approval Form