Pharmacy Authorization Exception Form - Health First printable pdf download

Pharmacy Authorization / Exception Form

Customer Service

Type of Request:

Toll Free: 1.844.522.5282

Prior Authorization

TDD Relay: 1.800.955.8771

Non-Formulary Medication

6450 US Highway 1

Quantity Limit Exception

Rockledge, FL 32955

Step Therapy Exception

Tiering Exception

Additional copies of this form can be found in our public website located at:

Important: If previous coverage

determination was Denied, please follow the

FAX COMPLETED FORM AND SUPPORTING DOCUMENTATION TO:

Appeals Process located in our secure

1.855.328.0061

provider portal located at:

Failure to complete this form in its entirety, including: Rationale for Exception Request,

Required Explanation, and supporting clinical documentation, may result in delayed processing

or an adverse determination for insufficient information.

Requesting Physician Information

Patient Information

Step 1:

Physician Name: _______________________________________________

Patient &

First Name:_____________________________________

physician

Contact Person: _______________________________________________

Last Name:_____________________________________

information

Phone: (______) ____________________________ Ext._______________

DOB: _______/_________/____________

Fax: (_______) ________________________________________________

Health First ID #: :________________________________

Drug Name:

Strength & Route of Administration:

Dosage/ Frequency:

Step 2:

Diagnosis

Qty:

HCPCS Code:

Expected Length of Therapy:

Place of Service:

and



Member picking up at the Pharmacy

Medical



Physician is Buying and Billing

Information

Drug Allergies (if applicable):

Diagnosis related to request

:__________________________________________

ICD dx Code:

________________________________________________________

*Attach Supporting Clinical Notes*

Step 3:

 Alternate drug(s) contraindicated or previously tried, but with adverse outcome (e.g., toxicity, allergy, or therapeutic failure)

Rationale for

 Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of

Exception

Request or

therapy on each drug(s);

Prior

 Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on

Authorization

current drug(s); high risk of significant adverse clinical outcome with medication change;

 Specify below: Anticipated significant adverse clinical outcome;

 Other: Explain below;

REQUIRED EXPLANATION: _______________________________________________________________________________________

_______________________________________________________________________________________________________________

 Please check here if the patient is receiving this medication as part of a clinical trial

Request for Expedited Review

EXPEDITED REVIEW TIMEFRAME IS 24 HOURS.

CRITERIA FOR EXPEDITED REVIEW: IF WAITING FOR A DECISION IN THE STANDARD TIMEFRAME COULD SERIOUSLY HARM THE MEMBER’S

LIFE, HEALTH OR ABILITY TO REGAIN MAXIMUM FUNCTION, YOU CAN ASK FOR AN EXPEDITED (FAST) DECISION.

CHECK HERE IF YOU ARE REQUESTING A FAST DECISION THAT MEETS THE CRITERIA ABOVE:

USE OF THIS FORM DOES NOT GUARANTEE ELIGIBILITY OF COVERAGE AND DOES NOT SUPERCEDE ANY MEMBER BENEFIT PLAN

LIMITATIONS OR THE PROVIDER’S CONTRACTUAL LIMITATIONS.

CONFIDENTIALITY: The information contained in this facsimile message may be legally privileged and confidential information intended only for the use of the

individual or entity named above. If the reader is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this telecopy

is strictly prohibited. If you have received this telecopy in error, please immediately notify the sender above and return the original message to us at the address

above by the United States Postal Service. Thank you for your cooperation.

AFFIRMATIVE STATEMENT: UM decision making is based only on appropriateness of care and service and existence of coverage.

Health First Health Plans does not reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for UM decision-

makers do not encourage decisions that result in under-utilization.

Health First Commercial Plans, Inc. and Health First Insurance, Inc., are both doing business under the name of Health First Health Plans. Health First Health

Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration

of the plan, including enrollment and benefit determinations.

27357-77150_MPINFO203 (07/16)

Pharmacy Authorization Exception Form - Health First

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