Infant Formulas - Medical Necessity Request Form printable pdf download

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

Horizon NJ Health

Infant Formulas – Medical Necessity Request

Women, Infants and Children Program (WIC) Information

Please complete this section for all initial (new) requests and for subsequent (renewal) requests if the number of cans needed has

increased.

Does the member qualify for the WIC (Women, Infants, and Children) program*? Yes or No

Has the member tried to obtain the medication through WIC? Yes or No

Does the member have a WIC medical necessity denial letter? Yes or No

Does WIC offer a viable alternative to the product being requested? Yes or No

If yes, can the physician prescribe the WIC-covered alternative? Yes or No

i. If no, why not? ______________________________

Is the request in excess of the number of cans that WIC allows? Yes or No

If yes, how many additional cans are being requested per month? _____

Are the additional cans medically necessary? Yes or No

* Please note that the member needs to try to obtain the medication through WIC first. If denied by WIC, a WIC medical

necessity denial letter must be obtained and faxed to HNJH at 609-538-0847.

Clinical Information

Please complete this section for all requests (initial and subsequent).

Does the member have a medically based or dietary risk? Yes or No

Please describe the member’s medically based or dietary risk:

_________________________________________________________________________________________________

___________________________________________________________________________________

Will this product be administered via a feeding tube (e.g., G-tube, NG-tube)? Yes or No

What is the member’s current weight? _________ lbs Date taken:_____________

_________kg

What is the member's current height/length? _______ inches

Date taken:_____________

________cm

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office.

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Rev. 03/16

HNJH Fax #: 888-567-0681

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Infant Formulas - Medical Necessity Request Form