Mdwise Medication Request Form (Mrf) For Healthy Indiana Plan (Hip) And Hoosier Care Connect (Hcc)

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®
Stelara
(ustekinumab)
Medication Request Form (MRF) for Healthy Indiana Plan (HIP) and Hoosier Care Connect (HCC)
FAX TO: (858) 790-7100
c/o MedImpact Healthcare Systems, Inc.
Attn: Prior Authorization Department
10181 Scripps Gateway Court, San Diego, CA 92131 - Phone: 1-800-788-2949
Instructions:
Step 1 - This form is to be used by participating providers to obtain coverage for the drug listed above which requires prior
authorization. Please complete this form and fax it to MedImpact Healthcare Systems, Inc. at (858) 790-7100. If you have any
questions regarding this process, please contact MedImpact’s Customer Service at (800) 788-2949.
Step 2 (if needed) - If you disagree with the final determination of this request (step 1), you can contact MDwise by phone, internet, U.S.
mail, fax, or in person. Please send your inquiry to the following address: MDwise Customer Service Department – Pharmacy Appeals,
PO Box 441423, Indianapolis, IN 46244-1426. Alternately, you may fax it to (844) 759-8548.
Member/Provider Information:
MDwise Member’s Name:
Provider’s Name:
MDwise Member’s ID #:
Provider’s Specialty:
MDwise Member’s DOB (mm-dd-yy):
Provider’s DEA #:
Pharmacy used by MDwise Member:
Provider’s Telephone Number/Contact Name (xxx-xxx-xxxx):
Pharmacy Telephone Number (xxx-xxx-xxxx):
Provider’s Fax Number (xxx-xxx-xxxx):
Clinical Information:
®
Requested Drug:
o Stelara
Dose and Quantity Requested:
Patients Current Weight: __________kg
Date weight was taken (mm-dd-yy): _____________
Date Requested:
Length of Treatment (please be specific):
Documentation of Medical Necessity (please check all that apply, completing both sections 1 & 2 if applicable):
Created: 12/11/2014
Reviewed/Revised: AMS
12/15/2015 11:24 AM

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