Generic Request Form PDF Details

In the realm of healthcare and prescription management, a critical tool that facilitates the intersection of patient care and regulatory compliance is the Generic Request Form. It's explicitly designed for use within the Department of Defense (DoD) TRICARE pharmacy program, with Express Scripts serving as the contractor. This form is a cornerstone in prescribing practices, requiring completion and signature by the prescriber when opting for a brand name drug over its generic counterpart. It navigates through a process that starts with basic patient and physician information, emphasizing the importance of A-rated generic drugs by the FDA for bioequivalence and therapeutic equivalence, underscoring the policy of mandatory substitution except under clinically justified circumstances. The form intricately lays out a step-by-step approach, addressing whether a patient has previously tried a generic product, their reaction to it, and detailed patient-specific clinical justifications for requiring a brand name drug. This mechanism not only upholds the standards set by the 32 CFR 199.21 (j)(2) regarding generic drug use but also prioritizes patient safety and efficacy. It ensures that the prescribed medication, brand name or generic, aligns with the patient’s health needs while adhering to regulatory mandates. The method of submission is made accessible via fax, mail, or email, illustrating the program's flexibility and adaptability to modern communication methodologies. In essence, the Generic Request Form bridges the gap between healthcare regulations, patient care, and the prescriber’s clinical judgment, marking a pivotal step in the prescription process for those under the DoD TRICARE pharmacy program.

QuestionAnswer
Form NameGeneric Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesgeneric request print, generic request template, generic request printable, generic request form template

Form Preview Example

Brand over Generic Prior Authorization Request Form

To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense (DoD) TRICARE pharmacy program (TPHARM). Express Scripts is the TPHARM contractor for DoD.

The provider may call: 1-866-684-4488 or the completed form may be faxed to:

1-866-684-4477

The patient may attach the completed form

to the prescription and mail it to: Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954

or email the form only to:

TpharmPA@express-scripts.com

Step

1

Please complete patient and physician information (Please Print)

Patient Name:

 

Physi cian Name:

Address:

 

Address:

 

Sponsor ID #

 

Phone #:

 

Date of Birth:

 

Secure Fax #:

Please indicate which medication is being prescribed: ________________________________________________

Step

2

Please consider the following:

32 CFR 199.21 (j)(2) Use of generic drugs under the pharmacy benefits program. The pharmacy benefits program generally requires mandatory substitution of generic drugs listed with an “A” rating in the current Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book) published by the FDA and generic equivalents of grandfather or Drug Efficacy Study Implementation (DESI) category drugs for brand name drugs. In cases in which there is a clinical justification for a brand name drug in lieu of a generic equivalent, under the standards and procedures of paragraph (h)(3) of this section, the generic substitution policy is waived.

The generic products are A-rated by the Food and Drug Administration for bioequivalence and therapeutic equivalence to the brand name product. An A-rated product will produce comparable absorption and blood levels to the brand name product. It is the judgment of the FDA that based on its determination of therapeutic equivalence between generic and innovator drug products, “products evaluated as therapeutically equivalent can be expected to have equivalent clinical effect whether the product is brand name or generic drug product.”

1. Has the patient tried the generic product?

 Yes

 

Proceed to Question 2

2. Did the patient experience a significant adverse

 Yes

reaction to the generic?

Proceed to Question 3

No

Proceed to Question 4

No

Proceed to Question 3

3.Please provide an explanation of the patient’s experience with the generic, then proceed to Step 3:

4.Please provide patient-specific clinical justification as to why the A-rated generic product cannot be used, then proceed to Step 3:

Step

I certify that the above is correct and accurate to the best of my knowledge. Please sign and date:

3

________________________________________

___________________

 

Prescriber Signature

Date

[ 5 May 2018 ]

How to Edit Generic Request Form Online for Free

There isn't anything difficult about filling out the generic request form for video once you start using our editor. By taking these easy steps, you'll get the ready PDF file in the least time period you can.

Step 1: Look for the button "Get Form Here" and press it.

Step 2: Now you are going to be on your form edit page. You can include, update, highlight, check, cross, include or erase fields or words.

You will have to type in the next data if you need to complete the file:

entering details in generic step 1

Within the segment Step, Prescriber Signature Date, and May enter the data that the system asks you to do.

generic Step, Prescriber Signature Date, and May blanks to insert

Step 3: Press the Done button to assure that your finalized form could be transferred to every electronic device you decide on or forwarded to an email you specify.

Step 4: You will need to make as many duplicates of the document as possible to remain away from future issues.

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