Medical Necessity Form For Daily Dose Exceeded/increase

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Member Name: ______________________________ Member ID: ___________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: __________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: ________________
Physician Fax #: _____________________ Pharmacy Name: _________________________Pharmacy Phone: __________________
Horizon NJ Health
Medical Necessity Form for Daily Dose Exceeded/Increase
Questions
Answers
1.
What are the directions for use? (For topicals,
please also provide the quantity requested for a 1-
month supply)
2.
Please document any other strengths of the SAME
Date filled:____________Prescriber:__________________
medication recently filled including the date filled,
Strength:_____________Quantity:_________DS:________
quantity, and days supply. (Circle NONE, if none
on file.)
Date filled:____________Prescriber:__________________
Strength:_____________Quantity:_________DS:________
NONE
3.
What is the diagnosis?
4. Is the patient starting at this dose/quantity?
Yes
No
5. If answer #5 Yes, why starting at this dose/quantity?
If request is for a topical product, please specify the
areas of application.
6. If answer #5 No, please ask the following questions:
a.
What was the previous dosing regimen?
___________________________(Previous dosing regimen)
b.
How long has the patient been on the previous
_________________________________________________
dosage regimen?
c.
Why increasing or giving this dose/quantity?
_________________________________________________
__________ lbs
Date Taken: __________________
7. What is the member’s current weight?
(Must be taken within the past 30 days)
__________ kg
___________ft/in
Date Taken: __________________
8. What is the member’s current height?
(Must be taken within the past 30 days)
___________cm
Physician office's signature*_________________________________ Print Name________________________________
* Form must be completed and signed by physician or licensed representative from the physician’s office
Rev. 03/16
HNJH Fax #: 888-567-0681
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