Prior Authorization Other Specialty Medications

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• * Required Field

• Enter Patient Information

• Drug Name: *
• Blue KC ID (Not SS#): *
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• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *
• Patient Group ID: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters and 2 decimals.
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• Has the patient been using samples? Yes No
• Dose and Directions: *
• Expected Date of Service: *
• Start Date:*
• End Date: *

• * Required Field

• Enter Provider Information

• Provider ID OR NPI: *
• Provider's Name: *
• Physician's Specialty: *
• Street Address: *
• City: *
• State: *
• ZIP Code: *
• Email Address:
• Phone Number:
  Enter a 10 digit phone number.
• Fax Number:*
  Enter a 10 digit phone number.
• Contact First Name: *
• Contact Last Name: *
• Contact Email Address: *
• Contact Phone Number: *
• Contact Phone Ext:
• Contact Fax Number:*

Drug Name and J-Code: *

• Weight (Kg): *

Previous medications tried and failed with dates: *

Physician Specialty:*

If service is not in your office, please list Infusion site or Facility/List ordering physician.

All Specialty medications must be provided by one of the following: *

If you have any additional information pertinent to this patient's therapy, please specify. Please attach any additional information to support the use of medications (Ex: Treatment plan, clinical documentation, lab results, etc.).

Insert Attachments.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.