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() 2018-2019 Prior Authorization Form - IEHP

() 2018-2019 Prior Authorization Form - IEHP-2025

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The document is a Prior Authorization Form for Synagis (palivizumab) for the 2018-2019 season, intended for submission to IEHP. It includes sections for patient and physician information, medical necessity criteria related to respiratory conditions in infants, additional risk factors, and prescription details. The form requires specific patient data such as age, weight, and previous treatment history to justify the need for Synagis injections.

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How do I submit a prior authorization to Medi-Cal?

Pharmacy providers and prescribers can submit a PA request via fax number 1-800-869-4325 by utilizing the preferred Medi-Cal Rx Prior Authorization Request Form or any of the following approved forms: 50-1, 50-2, 61-211.

What is the phone number for IEHP authorization?

prior authorization. please call (866) 725-4347.

What is the number for 1 800 440 4347?

If you have any questions, please call HealthLink at 1-877-284-0102.

What is the phone number for Medi-Cal authorization?

If you have a question about your coverage, call IEHP member Services at 1-800-440-IEHP (4347), Monday-Friday, 7 a.m.-7 p.m. and Saturday-Sunday, 8 a.m.-5 p.m. TTY users should call 1-800-718-IEHP (4347). Follow the advice and care procedures requested by your doctor and IEHP.

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