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Search Coverages for Your State Collegium Pharmaceutical

WEBWelcome to the Collegium Coverage portal. This website contains resources and our portfolio of products’ payer coverage information for top plans in your state. Select your …

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URL: https://collegiumcoverage.com/

The fax number for the OptumRx Prior-Authorization Request …

WEBPlease Note: The fax number for the OptumRx Prior-Authorization Request Form on the next page has changed. The new fax number is: 1-844-403-1027

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Belbuca Collegium Pharmaceutical Coverage

WEBBELBUCA ® (buprenorphine buccal film) is indicated for the management of severe and persistent pain that requires an extended treatment period with a daily opioid analgesic …

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Belbuca® Prior Authorization Request Form (Page 1 of 2)

WEBThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

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DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED …

WEB4. What is the member’s most recent score on a substance abuse/opioid dependence risk assessment tool? (Document score) ____ _____ 5.

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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE …

WEBFax Number: 1-855-633-7673. You may also ask us for a coverage determination by phone at 1-866-235-5660, TTY: 711, 24 hours a day, 7 days a week or through our website at …

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Request For Medicare Prescription Drug Coverage …

WEBThis form may be sent to us by mail or fax: Address: Cigna-HealthSpring Pharmacy Service Center Attn: Part D Coverage Determinations and Exceptions PO Box 20002 Nashville, …

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Request for Medicare Prescription Drug Coverage …

WEBRepresentation documentation for appeal requests made by someone other than enrollee or prescriber: Attach documentation showing the authority to represent the enrollee (a …

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PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP …

WEBPlan/Medical Group Name: Blue Shield of California Promise Health Plan Urgent or Non-Urgent: Plan/Medical Group Fax#: (323) 889-6254 or (866) 712-2731. Plan/Medical …

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MEDICARE PART D FORMULARY EXCEPTION INFORMATION

WEBONLY the prescriber may complete this form. This form is for Medicare Part D prospective, concurrent, and retrospective reviews. Please fax or mail this form to: Prime …

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Address: Fax Number: Blue Cross NC Blue Medicare HMOSM

WEBR Is the stated daily MED dose noted medically necessary? ☐YES ☐ NO Would a lower total daily MED dose be insufficient to control the enrollee’s pain?YES

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Medical Prior Authorization Form

WEBTo facilitate prompt and accurate processing, the information above must be complete and all supporting clinical documentation related to this request MUST be submitted with this …

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Request for Medicare Prescription Drug Coverage …

WEBH9047_2019RX12_C If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours.

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AUTHORIZATION/QUANTITY LIMIT EXCEPTION …

WEBFor Blue Cross NC members, fax form to 1-800-795-9403. GENERAL AUTHORIZATION/QUANTITY LIMIT EXCEPTION CERTIFICATION FAXBACK FORM. …

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MEDICARE PART D FORMULARY EXCEPTION INFORMATION

WEBPlease fax or mail the attached form to: Prime Therapeutics LLC Attn: Medicare Appeals Department TOLL FREE 2900 Ames Crossing Road Fax: 800-693-6703 Phone: 800 …

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