PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS. PLEASE FAX COMPLETED FORM TO 1-888-836-0730. I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this
Request for Budget Revision Form Request for Conference Attendance Form Request for Equipment Purchase Form; Request for LPAP Formulary Addition; Request for MNT Formulary Addition; Request for Service Category Increase Table Request for Van Transportation Medical Statement Request For Waiver Form; Service Utilization Report (SUR) Non-CPCDMS form
Browse our forms library for documentation on various topics including pharmacy, enrollment, claims and more. Prior Authorization Form Use this form when requesting prior authorizations, in- and out-of-network, and providing a supporting statement for an exception request Affinity Medical Management Prior Authorization Number: If you would like to request a Prior Authorization please dial: 888.543.9074 Non-Participating Provider Verification Form b. Completion of VA Form 10-0450, VHA National Formulary Request for Formulary Review; c. Completion of VA Form 10-0451, Conflict of Interest Disclosure Form, by the parties presenting the drug for formulary addition; and d. The signature of the VISN Pharmacist Executive, VHA Chief Medical Consultant, or Chief Medical Officer. To request a non-formulary drug exception: Fax a Non-Formulary Drug Exception Form to CVS Caremark at 1-888-836-0730; Call CVS Caremark at 1-855-582-2038; Tier Exception. You may submit a request for your patient to receive a non-preferred drug at a lower cost-sharing tier if the non-preferred drug is medically necessary. EnvisionRx Non Formulary Exception (NFE) Request Phone: 800-361-4542 Fax back to: 866-414-3453 EnvisionRxOptions manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above.
This form must be completed before the pharmacy can order and dispense a Non-Formulary drug. 1. The medication order must accompany this form. 2. Only attending physicians may initiate therapy with non-formulary drugs. 3. House staff may order non-formulary medications to continue treatment that was started prior to admission. 4.