Nutritional Supplements- Medical Necessity Request Form
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1Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Nutritional Supplements– Medical Necessity Request
For all members, please complete this section:
For members less than 5 years of age, please complete this section:
Current Weight: _______lbs. Date Taken*: _______
1.
Does the member qualify for the WIC (Women, Infants, and
_______kg
Children) program*? Yes or No
a.
Has the member tried to obtain the medication through
Weight 6 months ago: __________ lbs
WIC? Yes or No
__________kg
2.
Does the member have a WIC medical necessity denial letter?
Current Height: ______________ Date Taken: _________
Yes or No
* Weight must be obtained within the past 30 days for
3.
Does WIC offer a viable alternative to the product being requested?
initial requests and 60 days for subsequent (renewal)
Yes or No
requests
a.
If yes, can the physician prescribe the WIC-covered
alternative? Yes or No
i. If no, why not?
Will the member be eating or drinking any other
______________________________
food/pureed food besides the requested supplement)?
Yes or No
4.
Is the request in excess of the number of cans that WIC allows? Yes
o
If No, please provide clinical reason why
or No
member will not be eating or drinking any
a.
If yes, how many additional cans are being requested per
other food/pureed food besides the requested
month? _____
supplement _________________________
b.
Are the additional cans medically necessary? Yes or
___________________________________
No
Will this product be administered via a feeding tube
* Please note that the member needs to try to obtain the medication
(e.g., G-tube, NG-tube)? Yes or No
through WIC first. If denied by WIC, a WIC medical necessity denial
letter must be obtained and faxed to HNJH at 609-538-0847.
Diagnosis Information (please select diagnosis and provide requested information):
□ General Nutritional Deficiency/Weight
□ Dysphagia or Swallowing disorder (due to e.g stroke, brain
Loss/Anorexia/Underweight
injury, spinal cord injury, GERD, esophagitis)
- Please list specific disorder
□ Inability to swallow solid food. (Please indicate the specific
____________________________
reason member cannot swallow solid foods.)
□ Broken Jaw
□ HIV/AIDS Wasting
□ Anatomical inability to swallow (i.e. head and neck
□ Surgery
cancer or tumor of the esophagus or stomach)
□ Central Nervous system disease
□ Post-op
□ Receiving nutrition via feeding tube
□ Upcoming surgery
□ Other: _____________________________
- Is a liquid diet required? Yes or No
□ Inherited/Congenital Metabolic Disease or Condition (i.e.
□ Ketogenic Diet
Phenylketonuria, Cystic Fibrosis, etc.)
- Does the member have epilepsy? Yes or No
- Please list the specific disorder:
□ Failure to Thrive
______________________________
□ Pregnancy
□ Other: _______________________________
- Is the member currently pregnant? Yes or No
- Please provide the due date _______________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office.
1 of 1
Rev. 03/16
HNJH Fax #: 888-567-0681
Page
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