MHK-Provider Portal

Request Pharmacy Prior Authorizations

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Name:

Member ID:

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Date Of Birth:  
Benefit String:  
LOB:  
Address:  
IPA/MG:  
Pharmacy Benefit Indicator:  
Phone:  
Effective:  
Term:  
Special Programs:  
Case Manager:  
Standard         Expedited

Expedited Review

*Request Reason:

*Provider Information (*Denotes required field)

*Medication Request (*Denotes required field)

Medications

Action Medication Name NDC# Description Quantity Day Supply Dosage Form
Remove

Known Allergies

Allergies

Allergy Type Medication Specific Type Status Reaction/Observation Notes Date reported

*Diagnosis Information (*Denotes required field)

ICD - Search Results

Action ICD Number Description ICD Type
Remove 201.00 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION ICD-9

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Alternative Medications

Requested Medication: Nexium 40mg/1PA#: 12345678

  Formulary Alternatives

If an alternative medication below is appropriate click select. Otherwise proceed to the next section.


Alternative Medications

Action Medication Name Brand Type PA Requirement
Nexium Generic No PA Required
Omeprazole Generic No PA Required
Pepcid Generic No PA Required

To proceed with the current Authorization Request click the "NEXT" button below:


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Please upload additional documentation supporting your request including phone/fax contact information.

The request needs further clinical review. Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increase dose and if patient has any contraindications for the health plan/insurer preferred drug. Please provide any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier exceptions)or required under state and federal laws.

See below to upload documentation and add supporting notes related to the request.

Upload Supporting Documents (*Denotes required field)

Uploaded Documents

Action Document Name
Remove Rober_Smith_CCD

Notes

Action Note Text Date Note Type Id
Remove

Authorization Status:
Reason:
RX Case#:




Disclaimer:"Eligibility must be validated within 5 days of the actual date of service. We reserve the right to revoke authorizations based on cancellation of the member's eligibility. Final determination of benefits will be made after review of the submitted claim for limitations or exclusions. In accordance with the facility contract, prior authorization for inpatient facility services must be obtained to avoid potential reduction of payment for services rendered."

Authorization Status: Reason: RX Case#:


  Your request for the medication has been approved. The patient can now fill the medication at a pharmacy with a valid prescription. The correspondence has been mailed.

Authorization Status:

Need More Information

The request needs further clinical review. The plan will notify you of the outcome within required time frames


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Robbie Smith

 Member Not Eligible  Exp. 12/31/13

DOB:
01/07/1977

ADDRESS:
927 Twilight Dr, Cincinnati, OH 45240

EMAIL:
robbiesmith@gmail.com

Member ID#:
1457864

Insurance Company:
Home Town Health

Phone #:
614-555-1234

  This Member is NOT Eligible for Benefits


Please have member contact benefits manager if they believe this may be a mistake. Contact Home Town Health at 1-800-555-1234 or benefits@hometownhealth.com

If you believe you may have made a mistake please CLICK HERE to search again.

If this was not a mistake you can send the member a notification letter: Send


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