General Prior Authorization / Non-Formulary Medication - Coventry Cares Of Kentucky

ADVERTISEMENT

GENERAL PRIOR AUTHORIZATION/ NON-FORMULARY MEDICATION
Coverage Policy: Plans cover the cost of non-formulary drugs in patients who have not achieved the desired outcome from
adequate trail(s) of formulary agent(s) or in patients who have had intolerable adverse events from formulary agent(s). This form
may also be utilized for medications requiring prior authorization, when the only information required is a diagnosis, and previous
treatment trials and failures.
Some Prior Authorization Medications have forms specific to their coverage criteria. Whenever possible, these drug specific forms
should be used. They are designed to solicit more specific information (clinical notes, lab values, test results, etc.) needed to
determine the medical necessity of requested medication*
Requests meeting the following criteria will be considered:
Use for an FDA-approved indication
Intolerability or failure of other formulary medications used to treat the stated diagnosis; after an adequate trial
A listing of prior authorization drugs can be found at the plan website:
PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE – PHARMACEUTICAL SERVICES
FAX: (855) 799-2550 PHONE: (877) 215-4100 – Option 7
:
Requesting Physician:
Office Contact:
Call Center ID:
DEA Number:
Plan ID:
Benefit:
Office Fax Number:
Phone Number:
Office Address:
MEMBER INFORMATION
Patient Name:
DOB:
Member ID#:
Date of Request:
MEDICATION INFORMATION
Drug Requested:
1.
Dose:
Duration:
Diagnosis:
2.
List other formulary agents tried: (include all office notes and supporting documentation)
Drug:
Date(s) used:
Outcome:
3.
Date(s) used:
Outcome:
Drug:
Drug:
Date(s) used:
Outcome:
Other supporting information: (supporting clinical documentation is particularly important
when requesting an exception to coverage criteria for reasons of medical necessity.)
4.
PHYSICIAN’S SIGNATURE:
CHCMDC 1004-1 (10/11)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Prior Approval/non-formulary Medication Request Form - Blue Cross And Blue Shield Of Western New York - 2003 Prior Approval/non-formulary Medication Request Form - Blue Cross And Blue Shield Of Western New York - 2003 Business
Prior Authorization Request Form (synagis) - Utah Department Of Health Prior Authorization Request Form (synagis) - Utah Department Of Health Legal
Authorization To Consent For Health Care Of Minor Authorization To Consent For Health Care Of Minor Legal
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Medical
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Legal
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Legal
Texas Standard Prior Authorization Request Form For Health Care Services Texas Standard Prior Authorization Request Form For Health Care Services Medical
Form Nofr001 - Texas Standard Prior Authorization Request Form For Health Care Services Form Nofr001 - Texas Standard Prior Authorization Request Form For Health Care Services Legal
Form Dmas-p197 - Virginia Medicaid Request For Service Authorization Bowel Disorder Medications - Virginia Department Of Medical Assistance Services Form Dmas-p197 - Virginia Medicaid Request For Service Authorization Bowel Disorder Medications - Virginia Department Of Medical Assistance Services Legal
Form Fla - Amended Certificate Of Authority (foreign Limited Liability Company) - Commonwealth Of Kentucky Form Fla - Amended Certificate Of Authority (foreign Limited Liability Company) - Commonwealth Of Kentucky Legal

Related Categories

Parent category: Business
Download
Go