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MINNESOTA UNIFORM FORM FOR PRESCRIPTION DRUG PRIOR
AUTHORIZATION (PA) REQUESTS AND FORMULARY EXCEPTIONS
Please do NOT send this form to a patient’s employer or to the Minnesota Department of Health (MDH)
or to the Minnesota Administrative Uniformity Committee (AUC).
See additional instructions and overview, Instructions page.
Please check the appropriate box below. This form is being used for:
Formulary Exception
Prior Authorization (PA) Request Unsure/Unknown
A | Destination This form is being submitted to: (Payers making this form available on their websites may pre-populate section A.)
Payer Name: Payer Contact Name (IF AVAILABLE):
Payer Address: City, State, Zip:
Payer Phone: Secure Fax: Other:
B | Patient Information
When filling Patient Health Plan ID number below, please note: If the patient has prescription benefits that are separate or “carved out” from the health plan benefits, provide
the patient’s prescription benefit card ID number (the “cardholder ID”). If the patient’s prescription benefits are integrated with the health plan coverage (if there is no
separate prescription benefit ID number), provide the patient’s health plan ID number.
Patient Name (LAST, FIRST, MI): DOB: Gender:
Patient Address: City, State, Zip:
Health Plan or Prescription Plan: Patient Health Plan ID Number:
(OR PRESCRIPTION PLAN ID IF DIFFERENT THAN HEALTH PLAN ID)
C | Prescriber Information
Prescriber Name (LAST, FIRST, MI): NPI: Specialty:
Prescriber Business Address: City, State, Zip:
Health Plan or Prescription Plan: Patient Health Plan ID Number:
Prescriber Phone: Prescriber Secure Fax:
Prescriber
Point of Contact (POC) Name: POC Phone: POC Secure Fax:
(IF DIFFERENT THAN PRESCRIBER) (IF DIFFERENT THAN PRESCRIBER)
Clinic/Location/Facility Name: Clinic/Location/Facility Contact Name:
Clinic/Location/Facility Phone: Secure Clinic/Location/Facility Fax:
Clinic/Location/Facility Address: City, State, Zip:
"X" DEA number (buprenorphine prescriber status number, always preceded by "x," issued per the Drug Addiction Treatment Act of 2000 (Data 2000)):
D | Prescription Drug Information (Medication information)
When completing this section and the following section (E), medication "strength" is usually expressed in milligrams, e.g., 30mg, 15mg/ml, etc. Medication "dosing schedule"
is used to report how often the patient will take/use the medication, e.g, daily, four times per day, every four hours, as needed, etc. If request is for a Minnesota Department of
Human Services recipient, please also fill out Section F.
Drug Being Requested: Strength:
(REQUESTED DRUG NAME) (E.G., 30 MG, 15 MG/ML, ETC)
Dosing Schedule: Date Therapy Initiated:
Duration of Therapy Expected: Authorization Start Date:
Clinical Drug Trial Request? Is Dispense as Written (DAW) Specified?
(NOTE: THE MINNESOTA DEPT. OF HUMAN SERVICES DOES NOT COVER CLINICAL DRUG TRIALS)
Rationale for DAW?
Is patient currently being treated with the drug requested? Date Started:
This form was approved by the Commissioner of the Minnesota Department of Health