The CDPHP Medication Prior Authorization Form is also known as the CDPHP Prior Authorization / Medical Exception Request Form. Healthcare providers use it to request insurance coverage for specific medications not included in a patient's CDPHP formulary.
The form gathers comprehensive patient details, including full name, member ID, and date of birth. It also requires complete drug information such as the medication name, its strength, and the prescribed dosing regimen. Providers must document previous drug therapies tried, adverse reactions to formulary alternatives, and the medical rationale for the exception. All of this information supports the coverage decision made by the CDPHP Pharmacy Department.
Completed forms must be submitted by fax to (518) 641-3208 or mailed to the CDPHP Pharmacy Department at 500 Patroon Creek Blvd., Albany, New York 12206-1057. The department does not accept submissions by email. Patients needing similar forms for other insurers can also use the Aetna Pharmacy Prior Authorization Form or the general Pharmacy Prior Authorization Form.
| 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 |