Navigating the healthcare system often involves understanding and completing various forms, one of which is the CDPHP Medication Prior Authorization / Medical Exception Request Form. This essential document serves as a conduit between healthcare providers and the insurance provider, CDPHP, to request coverage for specific medications that are not immediately available through the patient's plan. The form is meticulously designed to gather comprehensive information about the patient, such as their full name, member ID, and date of birth, along with detailed drug information including the medication requested, its strength, and the prescribed dosing regimen. Additionally, it prompts the healthcare provider to answer critical questions regarding previous drug use, any adverse reactions to formulary medications, and past therapy trials, thus ensuring that the request is backed by a sound medical rationale. The form must be submitted by fax or mail to the CDPHP Pharmacy Department, highlighting the importance of traditional communication methods in the healthcare process despite the digital age. By providing a clear pathway for medical exceptions, the form plays a vital role in facilitating access to necessary medications for patients under CDPHP coverage, demonstrating the insurance provider's commitment to addressing individual healthcare needs.
| Question | Answer |
|---|---|
| Form Name | Cdphp Medication Prior Auth Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | cdphp prior auth form, cdphp prior authorization forms, cdphp prior authorization for radiology, cdphp medication prior auth form |
CDPHP Prior Authorization / Medical Exception Request Form
Fax or mail this form back to:
CDPHP Pharmacy Department, 500 Patroon Creek Blvd., Albany, New York
Phone: (518)
Patient Information:
Last Name:_________________________________ First Name:___________________________
Member ID #: _______________________________ Date of Birth:__________________________
Please check one: Medicare __ Select Plan (Medicaid)/Family Health Plus __ Other Plan Type __
Pharmacy & Phone (if known): ______________________________________________________
Drug Information:
Drug Requested: ___________________________________ Strength: _____________________
Dosing Regimen: ________________________________________________________________
Questions: |
|
1. Has the patient previously received this drug? |
Yes_____ No _____ |
How long has the patient been on this drug? |
____________________ |
2.If this patient had a documented allergy/adverse reaction on formulary medications,
describe:______________________________________________________________________
_____________________________________________________________________________
3.Document prior therapy trials and failures. (Include details of dose and duration of therapy)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4.Patient Diagnosis: _______________________________________________________________
Diagnosis Code (required): __________________
5.Describe
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Practitioner Information:
Practitioner Name: _____________________________ Practitioner Phone # __________________
Address:______________________________________ Fax (for notification):__________________
Nurse Contact: ________________________ Ext._____ Date: ______________________________
CDPHP reserves the right to review and audit charts as defined in the
Participating Physician Agreement, Section 12.3.