24 HOUR – URGENT
ATYPICAL ANTIPSYCHOTIC < 18
PRIOR AUTHORIZATION REQUEST FORM
Complete ENTIRE form and Fax to: 866-940-7328
Today‘s Date
SECTION A - PATIENT INFORMATION
First Name:
Last Name:
Member ID:
Address:
City:
State:
Zip:
Phone:
DOB:
Allergies:
Primary Insurance:
Policy #:
Group #:
Is the requested medication NEW □ or a CONTINUATION of THERAPY□? If so, start date:______________
Is this patient currently hospitalized? □ Yes □ No
SECTION B - PHYSICIAN INFORMATION
First Name:
Last Name:
M.D./D.O.
Address:
City:
State:
Zip:
Phone:
Fax:
NPI #:
Specialty:
Office Contact Name / Fax Attention to:
SECTION C - MEDICAL INFORMATION
Medication:
Strength:
Directions for use:
Diagnosis (Please be specific & provide as much information as possible):
ICD-10 CODE:
1. Does the patient have severe behavioral problems related to psychotic or neuro-developmental disorders?
□Autism Spectrum Disorder □Intellectual disability □Conduct disorder □Bipolar disorder
□Tic Disorder (Including Tourette’s Syndrome) □Transient encephalopathy □Schizophrenia □Other:______________________
2. Does the patient have chart documented evidence of a comprehensive evaluation, including non-pharmacologic therapies, such as, but not
limited to, evidence based behavioral, cognitive, and family based therapies? YES or NO ( circle answer)
3. Does the patient have documented baseline monitoring of weight or body mass index (BMI), blood pressure, fasting glucose, fasting lipid
panel, and extrapyramidal symptoms (EPS) using the Abnormal Involuntary Movement Scale (AIMS)? YES or NO ( circle answer)
4. Is the requested medication being prescribed by, or in consultation with a pediatric neurologist, child and adolescent psychiatrist or child
development pediatrician or general psychiatrist? YES or NO ( circle answer)
5. Has the patient tried and failed ALL available preferred antipsychotics (covered on the pharmacy benefit) that are FDA approved for the
patient’s age? YES or NO ( circle answer), If yes, please list below.
CONTINUATION of THERAPY ONLY:
1. Does the patient have documented improvement in target symptoms? YES or NO ( circle answer)
2. Does the patient have documented monitoring of weight OR BMI done quarterly? YES or NO ( circle answer)
3. Does the patient have documented monitoring of blood pressure, fasting glucose, fasting lipid panel, and EPS using AIMS after the first 3
months of therapy, and then annually? YES or NO ( circle answer)
5.Does the patient have a documented plan for taper/discontinuation of the antipsychotic OR rationale for continued use?
YES or NO ( circle answer)
Other Medications tried
Medications
Strength
Directions
Dates of Therapy
Reason for failure /
discontinuation
Physician Signature: ________________________________________ Date: _______________
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Phone: 800-310-6826
Fax: 866-940-7328
Website: www.uhccommunityplan.com
UHC-ATYPICAL ANTIPSYCHOTIC < 18 PA 1.12.16