Cdphp Prior Authorization/medical Exception Request Form
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2CDPHP Prior Authorization/
Medical Exception Request Form
Fax or mail this form back to:
CDPHP Pharmacy Department, 500 Patroon Creek Blvd., Albany, New York 12206-1057
Phone: (518) 641-3784 • Fax: (518) 641-3208
Patient Information
Last Name: __________________________________ First Name: _________________________________
Member ID #: ________________________________ Date of Birth: ________________________________
Please check one:
Medicare
Select Plan (Medicaid)
Other Plan Type _________________
Pharmacy and Phone (if known): ______________________________________________________________
Drug Information
Drug Requested: _____________________________ Strength: ___________________________________
Dosing Regimen: ___________________________________________________________________________
Questions
1. Has the patient previously received this drug? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
How long has the patient been on this drug? __________________________________________________
2. If this patient had a documented allergy/adverse reaction on formulary medications, describe:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Document prior therapy trials and failures. (Include details of dose and duration of therapy)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4. Patient Diagnosis: _________________________________________________________________________
Diagnosis Code (required): __________________
5. Describe patient-specific medical rationale: __________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
• Please complete the corresponding section for the specific drug/drug classes listed below if applicable •
For celecoxib request:
1. Short term use (30 days or less) pre/post a surgical procedure? . . . . . . . . . . . . . . .
Yes
No
2. Patient also utilizing oral steroids, anticoagulant or antiplatlet? . . . . . . . . . . . . . . .
Yes
No
3. Patient history of GERD, gastric/duodenal ulcer/bleed? . . . . . . . . . . . . . . . . . . . . . .
Yes
No
15-0263 • 0215
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Parent category: Business