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Medication Prior Authorization Request Form

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Preview of Medication PA Form
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Medication PA Form (Prescription_Prior_Authorization_Request_Form-2017.pdf)

221 KBktokunagaEN 3 pages
HPSJ will only accept the DMHC mandated state-wide prior authorization form (Form 61-211, revised 12/16) for medication prior authorization requests, effective
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Preview of Injectable Medication Policy
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Injectable Medication Policy (071 Injectable Specialty Medication Coverage prn.pdf)

211 KBMJAYARAO001EN 5 pages
Policy 071 covers injectable specialty medications under the pharmacy benefit for commercial members, excluding Medicare Advantage, Federal Employee Program,
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