Prior Authorization Drug Request
IMPORTANT INFORMATION REQUIRED -
FORM CANNOT BE PROCESSED WITHOUT REQUIRED DOCUMENTATION.
A separate request must be completed for each drug for each patient.
Date: _____________ Office Nurse/Manager: ___________________________________________
Prescriber: _____________________________ Office Phone#: _____________________________
Client: _______________________________ Office Fax#: _______________________________
Group: __________________
Patient: __________________________ DOB:________________
Member #: _______________________ Drug Name: _____________________________________
MaxorPlus Comments: The above patient has a prescription for a medication which requires a prior
authorization. This drug will be prior authorized if all the criteria have been met. Please indicate the
diagnosis, other treatments tried and any information relevant to the review of this request below and fax
the form back to us as instructed.
Dosage: Directions for use:
Quantity: Anticipated duration of therapy:
Diagnosis:
ICD-9 Code(s):
Indication:
Prior alternative treatment(s) provided for this condition:
Required Supporting Clinical Statement (such as protocols or evidence based guidelines followed,
concurrent therapies, comorbities, outcomes of previous drugs and therapies used, etc.):
Relevant Lab Values:
Prescriber Signature / Date:
Fax toll free to 844-370-6203 or mail to: MaxorPlus, 320 S. Polk, Suite 200, Amarillo, TX 79101
You will be notified within 24-48 hrs whether the request was approved. For inquiries, call 800-687-0707.
This form contains protected health information and is subject to all privacy and
security regulations under HIPAA.
