Medication Request Form printable pdf download

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Medication Request Form (MRF)

MedImpact Healthcare Systems, Inc.

DO NOT WRITE IN BLOCKED AREAS

Attn: Prior Authorization Department

FOR INTERNAL USE ONLY

Contacted:

Approved:

10680 Treena Street, Suite 500

Physician:

Denied:

San Diego, CA 92131

Pharmacy:

Returned:

Phone: 1-800-788-2949

Patient:

PA #

Fax: 858-790-7100

Patient request:

(Fax copy to Health Plan)

Instructions:

The prescribed medication below is non-formulary; to help lower this member’s co-pay please consider using a formulary alternative on the

Kaiser Foundation Health Plan of the Mid-Atlantic States (KPMAS), Inc.’s formulary at

If you have evaluated the member and believe that there are no suitable formulary alternatives available, please use this form to document

medical necessity in order for your patient to obtain coverage for the non-formulary

drug.

After completing this form, please fax to

MedImpact Healthcare Systems, Inc. within 24 hours at (858) 790-7100 or please call (800) 788-2949 with this information. If you have any

questions regarding this process, please contact MedImpact’s Customer Service at (800) 788-2949.

Please provide the information below: request will not be considered unless all sections have been completed.

Review Criteria:

e following criteria are used in reviewing non-formulary medication requests (PLEASE CHECK APPROPRIATE BOX):

□

The use of a formulary drug is contraindicated for the patient (allergy/adverse reaction to formulary drug).

□

The patient has failed an appropriate trial of the formulary drug alternatives or related agents.

□

The choices available on the KPMAS drug formulary are not suitable for this patient due to specific medical condition and/or drug is

required for optimal medication safety and therapeutic efficacy.

□

The use of a formulary drug may provoke an underlying medical condition, which would be detrimental to patient safety.

□

Patient requests the non-formulary drug when it is not medically necessary and agrees to pay the full price for the prescription.

Patient Name (required):

Patient’s Health Plan (required):

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Patient ID # (required):

Physician Name/Specialty:

Physician ID#/DEA #::

Patient DOB (required):

Physician Area Code and Telephone Number (required):

(

)

Diagnosis (required):

Physician Area Code and Fax Number (required):

(

)

Pharmacy used by member:

Pharmacy Area Code and Telephone Number:

(

)

Drug Requested:

Quantity (per month):

Dose:

Length of Treatment (please be specific):

Strength:

Dosage Form (e.g. Oral, Injection):

Reason for Medication Request (please be specific, give detail):

Other Medications Tried and/or Failed (please be specific, give detail):

Other Pertinent History (relative or pertaining to this request):

Physician Signature _________________________________ NPI___________

Date _________________

(Signature authorizes execution of the above instructions)

Revised: 10/26/09

Medication Request Form

Related Articles

Related forms

Related Categories