Medicare Member Part D Online Coverage Determination

This form may be sent to use by mail or fax.

Address:
First Choice VIP Care
200 Stevens Drive, Fourth Floor
Philadelphia PA , 19113
Attn: Pharmacy Prior Authorization/Member Prescription Coverage Determination

Fax Number:
Standard: (866)369-6038
Urgent: (866)533-5491

I need a drug that is not on the plan’s list of covered drugs (formulary exception).*

I have been using a drug that was previously included on the plan’s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).*

I request prior authorization for the drug my prescriber has prescribed.*

I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception).*

I request an exception to the plan's limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).*

My drug plan charges a higher copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).*

I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).*

My drug plan charged me a higher copayment for a drug than it should have.

I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

Any FDA NOTED CONTRAINDICATIONS to the requested drug? NO YES
Any concern for a DRUG INTERACTION with the addition of the requested drug to the enrollee's current drug regimen? NO YES

What is the daily cumulative Morphine Equivalent Dose (MED)? mg/day
Are you aware of other opioid prescribers for this enrollee? NO YES
Is the stated daily MED dose noted medically necessary? NO YES Would a lower total daily MED dose be insufficient to control the enrollee's pain? NO YES

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure [Specify below if not already noted in the DRUG HISTORY section earlier on the form:(1) Drug(s) tried and results of drug trial(s) (2) if adverse outcome, list drug(s) and adverse outcome for each,(3) if therapeutic failure, list maximum dose and length of therapy for drug(s) trialed, (4) if contraindiction(s), please list specific reason why preferred drug(s)/other formaulary drug(s) are contraindicated] Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change A specific explanation of any anticipated significant adverse clinical outcome would be expected is required - e.g. the condition has been difficult to control (many drugs tried, multiple drugs required to control condition), the patient had a significant adverse outcome when the condition was not controlled previously (e.g. hospitalization or frequent acute medical visits, heart attack, stroke, falls, significant limitation of functional status, undue pain and suffering),etc. Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage form(s) and/or dosage(s) tried and outcome of drug trial(s); (2) explain medical reason (3) include why less frequent dosing with a higher strength is not an option-if a higher strength exists] Request for formulary tier exception [Specify below if not noted in the DRUG HISTROY section earlier on the form: (1) Formulary or preferred drug(s) tried and results of drug trial(s) (2) if adverse outcome, list drug(s) and adverse outcome for each, (3) if therapeutic failure/not as effective as requested drug, list maximum dose and length of therapy for drug(s) trialed, (4) if contraindication(s), please list specific reason why preferred drug(s)/other formulary drug(s) are contraindicated] Other (explain below) Required Explanation

Enrollee's Name		Date of Birth
Enrollee's Address
Enrollee's Address 2
City	State	Zip Code
Phone	Enrollee's Member ID #

Requestor's Name		Requestor's Relationship To Enrollee
Address		Address 2
City	State	Zip Code
Phone

Name	Practice Name
NPI	Specialty
Address
Address 2
City	State	Zip Code
Office Phone	Fax	Contact Person
Prescriber's Signature:	Date:

Medication:	Strength and Route of Administration:	Frequency:
Date Started: New Start	Expected Length of Therapy:	Quantity per 30 days:
Height/Weight:	Drug Allergies:
DIAGNOSIS: Please list all diagnoses being treated with the requested drug and corresponding ICD-10 codes. (if the condition being treated with the requested drug is symptom e.g. anorexia,weight loss,shortness of breath,chest pain,nausea,etc., provide the diagnosis causing the symptom(s) if known)		ICD-10 Code(s)
Other RELEVANT DIAGNOSIS:		ICD-10 Code(s)

DRUGS TRIED: (if quantity limit is an issue,list unit dose/total daily dose tried)	Date of Drug Trials	RESULTS of previous drug trials FAILURE vs INTOLERANCE (explain)




What is the enrollee's current drug regimen for the condition(s) requiring the requested drug?

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

Type of Coverage Determination Request

Important Note: Expedited Decisions

Supporting Information for an Exception Request or Prior Authorization

Diagnosis and Medical Information

Drug History: (for treatment of the condition(s) requiring the requested drug)

DRUG SAFETY

HIGH RISK MANAGEMENT OF DRUGS IN THE ELDERLY

OPIOIDS-(please complete the following questions if the requested drug is an opioid)

Rationale for Request