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Request For Medicare Prescription Drug Coverage Determination Form - Blue Shield Of California Page 4

Prescriber's Information

Name _________________________________________________________________________

Address _______________________________________________________________________

City ____________________________________ State _______ Zip Code _________________

Office Phone_____________________________ Fax __________________________________

Prescriber’s Signature ______________________________________ Date________________

Diagnosis and Medical Information

Medication:

Strength and Route of Administration:

Frequency:

New Prescription OR Date

Expected Length of Therapy:

Quantity:

Therapy Initiated:

Height/Weight:

Drug Allergies:

Diagnosis:

Rationale for Request

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g.,

toxicity, allergy, or therapeutic failure [Specify below: (1) Drug(s) contraindicated or tried; (2)

adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)]

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with

medication change [Specify below: Anticipated significant adverse clinical outcome]

Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage

form(s) and/or dosage(s) tried; (2) explain medical reason]

Request for formulary tier exception [Specify below: (1) Formulary or preferred drugs

contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if

therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective,

length of therapy on each drug and outcome]

Other (explain below)

Required Explanation:___________________________________________________________

______________________________________________________________________________

Request For Medicare Prescription Drug Coverage Determination Form - Blue Shield Of California Page 4