Read General PA-NF FormMCP2011.doc text version

Managed Medicaid Plans

GENERAL Prior Authorization/Non-Formulary Medication

Coverage Policy: plans cover the cost of non-formulary drugs in patients who have not achieved the desired outcome from an adequate trial(s) of formulary agent(s) or in patients who have had intolerable adverse events from formulary agent(s). This form may also be utilized for medications requiring prior authorization, when the only information required is a diagnosis, and previous treatment trials and failures. Some Prior Authorization Medications have forms specific to their coverage criteria. Whenever possible these drug specific forms should be used. They are designed to solicit more specific information (clinical notes, lab values, test results, etc) needed to determine the Medical Necessity of requested medication.* Requests meeting the following criteria will be considered: Use for an FDA-approved indication Intolerability or failure to other formulary medications used to treat the stated diagnosis, after an adequate trial A listing of prior authorization drugs can be found at the plan websites: Diamond www.chcde.com Carenet www.yourcarenet.com CoventryCares PA www.mycoventrycares.com Omnicare www.omnicarehealthplan.com CoventryCares KY www.coventrycaresky.com PLEASE SEND COMPLETED FORM TO COVENTRY HEALTH CARE ­ PHARMACEUTICAL SERVICES F AX: Q 2 (877) 554-9137 PHO NE: (877) 215-4100 Requesting Physician: Call Center ID: Office Fax Number: Office Address: MEMBER INFORMATION Patient Name: Member ID#: MEDICATION INFORMATION DOB: Date of Request: Tax ID Number: Office Contact: Plan ID: Benefit: Phone Number:

Drug Requested: 1. Dose: 2. Diagnosis: List other formulary agents tried: (include all office notes and supporting documentation) Drug: ________________ Date(s) used: __________ Outcome: __________________ 3. Drug: ________________ Date(s) used: __________ Outcome: __________________ Drug: ________________ Date(s) used: __________ Outcome: __________________ Other supporting information: (Supporting clinical documentation is particularly important when

requesting an exception to coverage criteria for reasons of medical necessity.)

Duration:

4.

Physician's Signature:

CHCMDC 1004-1 (10/11) KYRX00004

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Fax Confidentiality Notice: The information contained in this transmission is confidential, proprietary or privileged and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act (HIPAA). The message is intended for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are notified that any use, distribution or copying of the attached material is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in error please notify us immediately by telephone at 1-877-215-4100.

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General PA-NF FormMCP2011.doc

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