1 Medicare part B Medication PRIOR authorization . request form Patient's Name: Date of Birth: ID #: Group #: Prescribing Doctor: Phone #: Pharmacy provider (If applicable): Phone #: Requested Medication : Name: Strength: Directions: Start Date: End Date: # of Doses Requested: Requested Medication : Name: Strength: Directions: Start Date: End Date: # of Doses Requested: Treatment Diagnosis: Other medications previously tried: Additional information supporting request (attach chart notes and/or labs if applicable): Comments: Sent by: Phone #: Please fax this form to 1-855-874-4711, Attention.
2 UM Intake For questions, call Customer Service at 1-877-774-8592. Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company (HISC), which is a wholly-owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for Medicare Advantage under contract H1666 with the Centers for Medicare and Medicaid Services. HISC is a Medicare Advantage organization with a Medicare contract. Y0096_APG_TMP_PartB Med PA form