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Exhibit B

HEALTHY FAMILIES OFFICE OF MANAGED CARE NON-FORMULARY DRUG PRIOR AUTHORIZATION REQUEST FORM

NOTE: Prior Authorization Requests without medical justification or previous medications listed will be considered INCOMPLETE. Illegible or incomplete forms will be returned.

PATIENT INFORMATION Patient Name

Date

HF ID#:

Primary Care Site

DOB

SEX

MEDICATION REQUEST Name of Drug

Strength

Quantity

Days Supply

Refills Sig.

Diagnosis

Treatment Plan & Duration

REASON FOR REQUEST

Treatment failure with formulary options (please specify):

Patient allergic to formulary alternative (please specify):

Other:

PHYSICIANS INFORMATION Prescriber Name

CA License No.

Specialty

Phone Fax

Primary Care Physician Name

Signature of Physician Requesting Drug

Strength

Qty.

Sig.

Strength

Qty.

Sig.

MEDICAL JUSTIFICATION/ INCLUDE OTHER MEDICATIONS TRIED AND RESULTS

1. Previous Medication

Duration (start/end date) & Results

2. Previous Medication

Duration (start/end date) & Results

3. Previous Medication

Strength

Qty.

Sig.

Duration (start/end date) & Results

HEALTHY FAMILIES/ OMC Approved by: (CHP Chief Medical Officer or Designee):

Date/Time:

AUTHORIZATION NUMBER:

Patient Identification: Name:

SSN:

DOB:

1000 S. Fremont Ave., Building A-9 East, 2nd

Floor, Unit #4, Alhambra, CA 91803 Tel(626)299-5539 Fax(626)299-7267

This Facsimile and any attached documents are confidential and are intended for the use of individual or entity to which it is addressed. If you have received this in error, please notify us by telephone immediately.

CHP Provider Manual 04/2004

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