Medication/Enteral Feed/Radiology Prior Authorizations

 

Given the practice pattern of modern day medicine in the US, one can somewhat understand the emergence of this degree of painful external practice “management”.  You should know that most reasonable insurance companies provide a comparable and efficacious list of alternative medications; therefore, before launching on this tedious endeavor, review the companies’ formulary or preferred medication list first.  Also consider using the fax PA forms that some companies provide.

 

Rx PA

·  Affinity Formulary  Abridged Formulary        Comprehensive Formulary With Explanation  (3/22 reportedly they don’t cover any ARBs without PA!)

                             Prior Authorization forms from CVS Caremark      Caremark phone 1 877 432 6793

1.      Other information  https://www.affinityplan.org/Affinity/Providers/Pharmacy.aspx

2.      https://www.affinityplan.org/Affinity/Providers/Drug_Formularies_Step_Therapies.aspx

·  Neighborhood Plan Formulary    Formulary                     Searchable Formulary               Quick Alternatives

1.      Prior Authorization forms from Express Script  

2.      General information  for Rx PA Call Express Scripts at 1800-287-0658

·  Health Plus  Formulary and PA form

·  Health First  http://www.healthfirstny.org/pdf/2011-Medicare/2011-NY-Formulary.pdf

·  Medicaid Traditional Fee for service- links to “preferred med list” and special Fax forms 1-877-309-9493

Since the fax PA process need 24 hrs for approval, you can tell your pt to go to the pharmacy the next day, and be sure to write on your prescription to let the pharmacist know to call Medicaid for pending PA number

 

Precertification for Radiology/Cardiac/PT/Testing

 

Affinity thru Care Core 1-866-242-5615  Prior authorization info page

Health Plus   1-800-450-8753  (required for 1st visit to PT, testings)

Health First Precert 1-866-394-4327 make sure you have member ID and location of referral

 

NY Medicaid (Fee for service only)

starting 4/2011 NY Medicaid will require PA on CTs, MRIs, PET, and nuclear cards testing.   Fax Request form

PA can be obtained by phone 1 888 209 4122 or by fax 1 888 209 9634  For links to fax form, diagnostic codes, or other info click here

 

For enteral feeding PA

 

 

Medicaid Enteral Formula Prior Authorization Program 1-866-211-1736 automated, to speak to live person for questions 1-800-342-3005

A new law as of May 2011 now only provides Enteral Formulas to pts who are either tube fed or dx with a inborn metabolic diseases.

Ms. Juana Moya in VC 205 can help you to call and obtain telephone PA #. Please complete the work sheet NYS/DOH Prior Authorization Work Sheet, and give her a copy of your enteral feed prescription (with 5 refills/6 months), be sure to include the fax number of the pt’s pharmacy. Ms. Moya will obtain the PA number from Medicaid and fax the Rx for you to the pharmacy. A copy will be placed in your mailbox for your records. To complete the form above, you will need the patients Medicaid number, DOB, ht/wt, your attendings license number. Each can of formula usually carries an average of 250-300 calories. For patients taking oral supplements (not tube feeding), be sure you have a good indication for PRESCRIBING the feed, i.e. wt loss, comordities that prevents adequate caloric intake, malnutrition… Although some of our patients would prefer to have some of these cans around at home (this stuff is over-the-counter and heavily marketed to the healthy population), basic medical necessities have to be met in order to have Medicaid cover this as part of your treatment.

 

For Medicare Part D RX PA

 

Medicare Part D Medication

Links to plans/formularies/standard fax PA forms and other info, also consider checking a very comprehensive site Fingertip Formulary