Metroplus Health Plan PDF Details

Millions of Americans rely on public health insurance programs like Metroplus Health Plan to receive quality, affordable healthcare. The process of applying for and enrolling in a plan can seem daunting, but with the help of this guide, you'll be able to complete the process quickly and easily. In this guide, we'll outline the steps involved in applying for Metroplus Health Plan and provide tips on how to make the process as smooth as possible. So whether you're just starting out on your healthcare journey or are looking to switch plans, read on for all the information you need.

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Form NameMetroplus Health Plan
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesmetroplus tax form, metroplus prior authorization form pdf, metroplus medicaid prior authorization, metroplus form pa for medications

Form Preview Example

Plan Name: ___________________

Plan Phone No. ______________

Plan Fax No.__________________

NYS Medicaid Prior Authorization Request Form For Prescriptions

Rationale for Exception Request or Prior Authorization - All information must be complete and legible

Patient Information

First Name:






Last Name:





























Date of Birth:

Member ID:



Is patient transitioning from a facility?


























If yes, provide name of facility: _________________________________________________






























Provider Information




























First Name:





Last Name:



























NPI No:1


Phone No:


Fax No:

Office Contact:









































Medication/Medical and Dispensing Information























































Case Specific Diagnosis/ICD9:2

Route of


Oral IM SC Transdermal IV Other











For physician administered, will this provider be ordering & administering?










If no, supply administering provider:





























Please check one of the following:

This is a new medication and/or new health plan for the patient. If checked, go to question 1

This is continued therapy previously covered by the patient’s current health plan.

If checked, approx. date initiated _____/_____. Go to question 5

1.Does the drug require a dose titration of either multiple strengths and/or multiple doses per day?

If yes, provide titration schedule: _________________________________________________________

2.Is the drug being used for an FDA approved indication?

2.(a) If the answer to 2 is No, is its use supported by Official Compendia (AHFS DI®, DRUGDEX ®)3

3.Has the patient experienced treatment failure with a preferred/formulary drug(s) or has the patient experienced an adverse reaction with a preferred/formulary drug(s) in the therapeutic class? If yes, complete the following:






No No


Drug and Dose

Route Frequency Approx. date range therapy began & stopped


_____/_____ _____/_____

_____/_____ _____/_____

4.Is there documented history of successful therapeutic control with a non-preferred/non-formulary drug and transition to a preferred/formulary drug is medically contraindicated? If yes, explain:

Yes No

5. Is this a change in dosage/day for the above medication?

6. Attach relevant lab results, tests and diagnostic studies performed that support use of therapy. Check if attached

Yes No

Required clinical information: Please provide all relevant clinical information in the box below to support a medical necessity to determine coverage. Refer to health plan coverage requirements for the requested medication (see link above).

Please check here if documentation is attached.

7. Does the request require an expedited review?

Yes No

Attestation: I attest that this is medically necessary for this patient and that all of the information is accurate to the best of my knowledge. I attest that documentation of the above diagnosis and medical necessity is available for review if requested by the Health Plan. PLEASE NOTE: The Health Plan may request information in addition to what is on the form in order to make a determination.

Prescriber’s Signature _________________________________________________________

Date ____/____/______



Informaion on this form is protected health informaion and subject to all privacy and security regulaions under HIPAA.

page 1 of 2

Instructional Information for Prior Authorization

Upon our review of all required information, you will be contacted by the health plan.

When providing required clinical information, the following elements should be considered within the rationale to support your medical necessity request:


OCompound ingredients

OSpecific dosage form consideration

ODrug or Other Related Allergies

Please consider providing the following information as applicable & when available:

OHealthcare Common Procedure Coding System (HCPCS) 4

OTransition of Care (contact, phone number, length of stay)

OPatient information (address, phone number)

OProvider information (address, direct electronic contact information, e-mail, etc.)

This form must be signed by the prescriber but can also be completed by the prescriber or his/her authorized agent. The completed fax form and any supporting documents must be faxed to the proper health plan.

Helpful Definitions

1NPI: A national provider identifier (NPI) is a unique ten-digit identification number required by HIPAA for all health care providers in the United States. Simplification/NationalProvIdentStand/index.html?redirect=/nationalprovidentstand/

2ICD-9: The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics

3AHFS Drug Information® (AHFS DI®) provides evidence-based evaluation of pertinent clinical data concerning drugs, with a focus on assessing the advantages and disadvantages of various therapies, including interpretation of various claims of drug efficacy. DRUGDEX ® System within the Micomedex product which provides peer-reviewed, evidence-based drug information including investigational & non prescription drugs.

4The HCPCS is divided into two principal subsystems, referred to as level I and level II of the HCPCS:

OLevel I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.

OLevel II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established for submitting claims for these items.


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metroplus prior authorization request empty fields to fill in

You have to enter the appropriate details in the Does the drug require a dose, No No No, an adverse reaction with a, Drug and Dose, Route Frequency Approx date range, Outcome, began stopped, Is there documented history of, preferredformulary drug is, Is this a change in dosageday for, Required clinical information, Please check here if documentation, Does the request require an, and Attestation I attest that this is field.

metroplus prior authorization request Does the drug require a dose, No No No, an adverse reaction with a, Drug and Dose, Route Frequency Approx date range, Outcome, began  stopped, Is there documented history of, preferredformulary drug is, Is this a change in dosageday for, Required clinical information, Please check here if documentation, Does the request require an, and Attestation I attest that this is fields to complete

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