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body{
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h1,h2,h3,h4,h5,h6{
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.main-header .navbar{
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.content-wrapper, .main-footer{
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.wrapper{
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}
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padding-top: 30px;
display: flex;
margin-bottom: 25px;
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float: left;
margin-left: 0;
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</head>
<body class="skin-blue layout-boxed" style="height: auto; min-height: 100%;">
<!-- Site wrapper -->
<div class="wrapper" style="overflow: hidden; height: auto; min-height: 100%;" id="ajaxPageHolder"><!-- Left side column. contains the logo and sidebar -->
<div class="u12_div">
<div style="float: left;padding:6px;width: 100%;">
36 years old, M, Talofofo, GU <br>
Maki, Deke </div>
<div class="pull-right" style="padding:6px;width: 100%;text-align: end;">
<b>Pharmacy Benefit Prior Authorization</b> <br>
Xolair 150 mg vial </div>
</div>
<!--<script type="text/javascript" src="https://qaspnrx.evincemed.net/assets/check_browser_tab_close.js"></script>-->
<style>
.section-title{
background-color: #d9eff0;
margin-left: 3%;
width: 94%;
margin-bottom: 10px;
}
.section-title h4{
font-size: 16px;
font-weight: bold;
}
.small, small {
font-size: 70%;
font-style: italic;
}
</style>
<script>
$(document).ready(function () {
// Send data to Server
$('#sub_btn').click(function (e) {
e.preventDefault();
var errMsg = [];
var drugSigText = $("#drugSigText").val();
var drugQuantity = $("#drugQuantity").val();
var drugDaysSupply = $('#drugDaysSupply').val();
var bin = $("#bin").val();
var pbmMemberId = $("#pbmMemberId").val();
var CardHolderID = $("#CardHolderID").val();
if (drugSigText == '') {
$('#drugSigText').addClass('field_error');
errMsg.push(' Please enter Signote ');
} else {
$('#drugSigText').removeClass('field_error');
}
if (bin == '' || bin.length != 6) {
$('#bin').addClass('field_error');
errMsg.push(' Please enter 6 digit BIN ');
} else {
$('#bin').removeClass('field_error');
}
if (pbmMemberId == '') {
$('#pbmMemberId').addClass('field_error');
errMsg.push(' Please enter pbmMemberId ');
} else {
$('#pbmMemberId').removeClass('field_error');
}
if (CardHolderID == '') {
$('#CardHolderID').addClass('field_error');
errMsg.push(' Please enter CardHolderID ');
} else {
$('#CardHolderID').removeClass('field_error');
}
if (drugQuantity == '') {
$('#drugQuantity').addClass('field_error');
errMsg.push(' Please enter drug quantity ');
} else {
$('#drugQuantity').removeClass('field_error');
}
if (drugDaysSupply == '') {
$('#drugDaysSupply').addClass('field_error');
errMsg.push(' Please enter drug days supply');
} else {
$('#drugDaysSupply').removeClass('field_error');
}
if (errMsg.toString() != "") {
$.confirm({
icon: 'fa fa-warning',
theme: 'modern',
closeIcon: true,
animation: 'scale',
type: 'red',
title: 'Alert!',
content: errMsg.toString(),
buttons: {
close: function () {
}
}
});
return false;
} else {
//alert('Form will be submit!');
$('#sub_btn').attr('disabled', true);
// setup some local variables
var $form = $('#epaInitiateForm');
var serializedData = $form.serializeArray();
$.post("https://qaspnrx.evincemed.net/v1/epa/post_process_epa_form", serializedData, function (data) {
// Display the returned data in browser
console.log(data);
//console.log(successs);
const obj = JSON.parse(data);
if (obj.Status == false) {
$('#sub_btn').attr('disabled', false);
$.confirm({
icon: 'fa fa-error',
theme: 'modern',
closeIcon: true,
animation: 'scale',
type: 'red',
title: 'Alert!',
content: obj.Message,
buttons: {
close: function () {
}
}
});
} else {
$.confirm({
icon: 'fa fa-success',
theme: 'modern',
closeIcon: false,
animation: 'scale',
type: 'green',
title: 'Alert!',
content: "Prior Authorization has been initiated.",
buttons: {
close: function () {
$.get("https://qaspnrx.evincemed.net/v1/epa/thankyou", function (res, status) {
$("#ajaxPageHolder").html(res);
});
}
}
});
}
});
}
});
});
</script>
<section class="content">
<div class="box box-default">
<div class="box-header no-border">
<div class="box-tools pull-right">
</div>
</div>
<!-- /.box-header -->
<form method="post" id="epaInitiateForm">
<input type="hidden" name="ref_id" value="729C8338BECDA6E7A262CCAE28FF815D">
<input type="hidden" name="auth_username" value="amgen">
<input type="hidden" name="sso_userID" value="devuser">
<input type="hidden" name="EMID" value="22150">
<input type="hidden" name="Urgent" value="">
<input type="hidden" name="PayerID" value="T00000000023152">
<input type="hidden" name="PayerName" value="Pruebas PBM">
<input type="hidden" name="GroupName" value="GUAM-2">
<input type="hidden" name="EligibilityMessageID" value="9999999">
<input type="hidden" name="PatientFirstName" value="Deke">
<input type="hidden" name="PatientLastName" value="Maki">
<input type="hidden" name="PatientMiddleName" value="James">
<input type="hidden" name="PatientSuffix" value="">
<input type="hidden" name="PatientGender" value="M">
<input type="hidden" name="PatientDob" value="1985-08-11">
<input type="hidden" name="PatientAddressLine1" value="11 Talofofo Road">
<input type="hidden" name="PatientAddressLine2" value="4A">
<input type="hidden" name="PatientCity" value="Talofofo">
<input type="hidden" name="PatientState" value="GU">
<input type="hidden" name="PatientZip" value="969150000">
<input type="hidden" name="PatientPhone" value="9685968500">
<input type="hidden" name="ProviderNPI" value="1518961887">
<input type="hidden" name="PrescriberLastName" value="PICCIONE">
<input type="hidden" name="PrescriberFirstName" value="FRANCIS">
<input type="hidden" name="PrescriberAddressLine1" value="718 SMYTH RD">
<input type="hidden" name="PrescriberAddressLine2" value="">
<input type="hidden" name="PrescriberCity" value="MANCHESTER">
<input type="hidden" name="PrescriberState" value="NH">
<input type="hidden" name="PrescriberZip" value="031047007">
<input type="hidden" name="PrescriberPhone" value="6036244366">
<input type="hidden" name="PrescriberFax" value="6030304304">
<input type="hidden" name="UserType" value="Prescriber">
<input type="hidden" name="UserID" value="devuser">
<input type="hidden" name="UserLastName" value="User">
<input type="hidden" name="UserFirstName" value="Test">
<input type="hidden" name="UserPhoneNo" value="9999999999">
<input type="hidden" name="UserFaxNo" value="7034145557">
<div class="box-body">
<div class="col-md-8">
<!-- <div class="row">
<div class="col-md-6 form-group">
<label for="prescriberFirstName">PA Reference ID<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval" required="true" value="89898989" name="PAReferenceID" id="PAReferenceID" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="prescriberFirstName">Ordering /Prescribing Physician<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval" required="true" value="PICCIONE, FRANCIS - 1518961887" name="orderingPrescriber" id="orderingPrescriber" placeholder="">
</div>
</div> -->
<!-- /.row -->
<div class="row">
<input type="hidden" name="DrugDescription" value="Xolair 150 mg vial">
<input type="hidden" name="DrugNDC" value="50242004062">
<div class="col-md-6 form-group">
<label for="drugSigText">Sig.<sup style="color: red;">*</sup> <small>max 140 characters</small></label>
<input type="text" class="form-control requiredval" value="Inject 225 mg subcutaneously once every 2 weeks" name="DrugSigText" required="true" id="drugSigText" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="drugSigText">Select Insurance</label>
<select type="text" class="form-control requiredval" value="Inject 225 mg subcutaneously once every 2 weeks" name="DrugSigText" required="true" id="drugSigText" placeholder="">
<option>Select Insurance</option>
<option>Option 1</option>
<option>Option 2</option>
<option>Option 3</option>
</select>
</div>
<div class="col-md-6 form-group">
<label for="bin">Bin No</label>
<input type="text" class="form-control requiredval numval" maxlength="6" value="004951" name="BIN" required="true" id="bin" placeholder="">
</div>
<!-- <div class="col-md-6 form-group">
<label for="drugPackageRefills">Package Unit <small>optional</small></label>
<input type="text" class="form-control" value="C64933" name="DrugQuantityUnitOfMeasure" id="DrugQuantityUnitOfMeasure" placeholder="">
</div> -->
<div class="col-md-6 form-group">
<label for="pbmMemberId">PBM Member ID</label>
<input type="text" class="form-control requiredval numval" value="PBS$GU923312-51R211" name="PBMMemberID" required="true" id="pbmMemberId" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="drugQuantity">Quantity<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval numval" value="6" name="DrugQuantity" required="true" id="drugQuantity" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="pbmMemberId">Card Holder ID</label>
<input type="text" class="form-control requiredval" value="GU2-MAKID" name="CardHolderID" required="true" id="CardHolderID" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="drugDaysSupply">Days Supply<sup style="color: red;">*</sup></label>
<input type="text" class="form-control requiredval numval" value="60" name="DrugDaysSupply" required="true" id="drugDaysSupply" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="pcn">PCN</label>
<input type="text" class="form-control numval" value="4951-GU2" name="PCN" id="pcn" placeholder="">
</div>
<!-- <div class="col-md-6 form-group">
<label for="commercial_drugNumberOfRefills">Refills</label>
<input type="text" class="form-control numval" value="1" name="DrugNumberOfRefills" id="drugNumberOfRefills" placeholder="">
</div> -->
<div class="col-md-6 form-group">
<label for="group_id">Group ID</label>
<input type="text" class="form-control" value="GP-GU2" name="GroupID" id="group_id" placeholder="">
</div>
<div class="col-md-6 form-group urgent_section">
<!--<label for="PrimaryICDCode">Urgent</label> -->
<input type="checkbox" class="mt-0" style="height: 20px;width: 20px; margin-top: 0;" name="PrimaryICDCode" id="UrgentCheckbox" >
<label for="PrimaryICDCode" class="mb-0" style="margin-bottom:0;margin-left: 5px;">Urgent</label>
</div>
<div class="col-md-6 form-group">
<label for="PrimaryICDCode">Primary Diagnosis Code</label>
<input type="text" class="form-control" value="J4540" name="PrimaryICDCode" id="PrimaryICDCode" placeholder="">
</div>
<div class="col-md-6 form-group">
<label for="SecondaryICDCode">Secondary Diagnosis Code</label>
<input type="text" class="form-control" value="" name="SecondaryICDCode" id="SecondaryICDCode" placeholder="">
</div>
</div>
<!-- /.row -->
</div>
<div class="col-md-4" style="
padding: 0;
">
<div class="col-md-12">
<label>Ordering/Prescribing Physician Information</label>
</div>
<div class="col-md-12">
<label>Name: </label>
PICCIONE, FRANCIS - 1518961887 </div>
<div class="col-md-12">
<label>NPI: </label>
1518961887 </div>
<div class="col-md-12">
<label>Address: </label>
718 SMYTH RD, MANCHESTER, NH, 03104-7007 </div>
<!-- <div class="col-md-12">
<label>City/State/Zip</label><br>
MANCHESTER, NH, 031047007 </div> -->
<div class="col-md-12">
<span class="phone_label">
<label>Phone:</label> (603)-624-4366
</span>
<span class="fax_label ml-2">
<label>Fax:</label> (603)-030-4304</span>
</div>
</div>
<div class="clearfix"></div>
<center><button type="button" id="sub_btn" class="btn btn-block btn-danger btn-lg" style="width: 300px;">Initiate Prior Authorization</button></center>
</div>
<!-- /.box-body -->
</form>
</div>
</section></div>
<!-- ./wrapper -->
</body></html>