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Preferred Medication for Asthma Patients ≥12 Years (1023 KB)

Prescription Authorization Requests 

Before submitting a Prescription Medicine Prior Authorization Request (PAR) Form, search HPSM’s formulary for the medicine you want to prescribe. Make sure you search the formulary for the member’s specific health plan.

  • If the medicine you searched is in the formulary, you do not need to submit the authorization form.
  • If the medicine you searched is not in the formulary or has the initials NF, PA, QL or ST next to it, then complete the Prescription Medicine PAR Form and fax it to HPSM at 650-829-2045.

Download the Prescription Medicine Prior Authorization Request Form

Required Clinical Information

Please provide:

  • Symptoms.
  • Lab results with dates and/or justification for initial or ongoing therapy or increased dose.
    • Lab results with dates must be provided if needed to establish diagnosis or evaluate response.
  • Information on whether the patient has any contraindications for the health plan/insurer preferred medicine.
  • Any additional clinical information or comments pertinent to this request for coverage (e.g. formulary tier exceptions) or required under state and federal laws.

If you have any questions about the Prescription Medicine PAR Form, please call HPSM’s Pharmacy Services at 650-616-2088.

CareAdvantage Coverage Limitations and Exceptions

Prior Authorization Criteria (PA)

These medicines are in the CareAdvantage Formulary but need to be pre-approved before you fill a prescription. This also includes the criteria for approval of each medicine.

 

Quantity Limits (QL)

These drugs are covered but have a set limit on the amount of pills per prescription and the number of times they can be refilled without further authorization.

 

Step Therapy Criteria (ST)

Some drugs are covered only after you have a tried a recommended drug, but it did not work. When there are two drugs for your condition, CareAdvantage may require you to try one drug first before covering the other drug.

 

Pharmacy Authorization Forms
Community-Based Adult Services (CBAS) Referral Form
Formulary Modification Request Form
Prescription Drug Authorization Request Form

Pharmacy Authorization Fax Numbers

Prescription drug prior authorization:

650-829-2045

Incontinence supply authorization:

650-829-2079