Physicians Health Plan Of Mid Michigan

Medical Exception for Medication

******* MUST HAVE ALL INFORMATION TO PROCESS*******

Fax to Physicians Health Plan (517) 364-8413 (

Phone (517) 364-8545

Office & Fax Monday-Friday 8am-5pm except holidays)

Physicians Health Plan (HMO)

PHP Insurance Company (PPO)

PHP Service Company (TPA)

Sparrow PHP

Today’s Date:

Provider/NPI Number:

Member Name:

Office Address:

Member ID#

DOB:

Sex:

Office Contact:

Physician Name:

Phone:

Fax:

Medication Information

Diagnosis & ICD Code (s):

Infusion HCPCS Code:

Medication

Strength/Form

Dosing/# Per Month

*Infusion Medication Will Be Given

In Office

Out-Patient Facility Name of Hospital/Clinic____________

Previous Therapies Attempted

Patients Weight: _________________

Therapies Attempted

Strength and

When/How Long

Reason for Discontinuation

Dose

**

**

Current chart notes required

Additional comments here:

Physician/Designee Signature:

Date:

Requests will be reviewed in the order it is received.

Final determinations will be returned within a maximum of 14 days

OUTCOME (PHP Use Only)

Covered - Good through:

Not Covered – Reason:

Pharmacist/Designee Signature:

Date:

Denial Sustained - Must have NEW/REQUESTED information to continue review.

Pharmacist/Designee Signature:

Date:

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