If you are taking medication on a regular basis, it is important to know if that medication requires prior auth from your insurance company. CDPHP requires all members to get prior auth for prescriptions that are not listed on the formulary. This can include both brand name and generic drugs. In order to save time and avoid delays in getting your medications, be sure to check ahead of time whether or not a prior auth is necessary. You can find the formulary online at cdphp.com/formularies, or by speaking with a representative from customer service.
| 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.