Silverscript Procrit Pa Form PDF Details

Are you in need of a form for Procrit? If so, the Silverscript Procrit Pa form may be what you are looking for. This form is designed to help those who need to take this medication. It is important that you understand how to use this form and what it is for before you begin using it. With that in mind, let's take a closer look at the Silverscript Procrit Pa form. What does the Form include? When looking at the Silverscript Procrit Pa form, there are a few things that stand out immediately. The first thing is that it includes detailed information on how to take this medication. It also includes information on when and how to contact your doctor if needed.

You can find information regarding the type of form you need to complete in the table. It can show you the time it should take to fill out silverscript procrit pa form, what fields you will have to fill in and several further specific facts.

QuestionAnswer
Form NameSilverscript Procrit Pa Form
Form Length2 pages
Fillable?Yes
Fillable fields56
Avg. time to fill out11 min 46 sec
Other namessilverscript form, silverscript prior auth, silverscript prior auth form, silverscript non formulary exception form 2021

Form Preview Example

Fax completed form to: 1-855-633-7673

Questions, please call: 1-855-344-0930

24 hours a day 7 days a week (TTY users call: 711)

Important Information about Prescription Drug Coverage

To:From:

Fax:Pages:

Re: Request for Coverage of a Non-Formulary Drug: Please respond.

Please complete the attached Request for Coverage of a Non-Formulary Drug Form.

To prevent delays in the review process please complete all requested fields.

Completed forms should be faxed to: 1-855-633-7673. It is not necessary to fax this cover page.

Information about this Request for Coverage of a Non-Formulary Drug

Use this form to request coverage of a drug that is not on the formulary. To process this request, documentation that all formulary alternatives would not be as effective or would have adverse effects is required. Please provide clinical information or other evidence supporting the medical necessity of the non-formulary drug, including previous formulary drugs attempted for this patient's condition. If the formulary exception is approved, it will be reimbursed at the highest brand tier copay for the calendar year.

You can make an expedited request by indicating this at the top of the attached form. If you request an expedited review and sign the attached form, you certify that applying the 72 hour standard review time frame may seriously jeopardize the life or health of the member or the member's ability to regain maximum function.

Information on the attached form is protected health information and subject to all privacy and security regulations under HIPAA.

Member privacy is important to us. Our employees are trained regarding the appropriate way to handle our members' private health information.

CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.

5246-24762a 011912

Silverscript® Insurance Company

Fax completed form to: 1-855-633-7673

 

Questions, please call: 1-855-344-0930

 

24 hours a day 7 days a week

 

(TTY users call: 711)

Request for Coverage of a Non-Formulary Drug

Patient Information

Name

Member ID -

Medicare ID

Date of Birth

Sex:

M /F

 

 

 

Address

 

 

 

 

 

City

 

--

 

 

 

State

 

 

ZIP

 

 

Phone

 

 

 

 

 

Nursing Home Resident

 

YES / NO

 

Home care patient?

 

YES / NO

 

 

Prescriber and Pharmacy Information

___

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

Phone

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NCPDP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

All items below this line are for Physician Use Only

 

 

 

 

Information for Requested Drug

 

 

 

 

 

 

 

 

Drug Name: ----------------------------------------------------

 

 

 

 

 

 

Drug Requested is (circle one): Brand /Generic

Strength:

 

Dosage form:

 

Qty per 30 days:

 

Drug is (circle one):Newly prescribed /Refill

 

 

 

 

 

 

 

 

 

 

 

 

 

Directions:

 

 

 

 

Diagnosis:

 

 

 

 

 

 

 

 

 

ICD-10 Code:

 

 

Standard Reviews will be completed in under 72 hours. An expedited

 

 

 

 

 

 

 

 

 

 

 

 

 

 

review is available if you certify that a standard review time frame will seriously jeopardize the health of your patient. To request an expedited review, simply indicate this at the top of this page.

Request for Coverage of a Non-Formulary Drug Criteria

Medical Justification: Please provide medical justification for the non-formulary drug exception request. Please address why all formulary alternatives on any tier of the formulary for treatment of the same condition would not be effective or would cause adverse effects. List previous drugs and doses attempted for this patient, condition and dates or approximate dates or duration of treatment (if known). Document adverse effects requiring discontinuation and/or reason for perceived ineffectiveness. Attach additional pages if necessary.

If all formulary agents would not be effective, please specify prior treatment failures:-------------------

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If all formulary agents would have adverse effects, please specify prior adverse effect history:---------

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If patient preference for nonformulary drug, please provide your clinical rationale:---------------------

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If no available formulary alternatives have been previously tried, please check this box.

I attest that the information provided on this form is true and accurate as of this date:

Prescriber's signature:

Date:

 

 

 

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silverscript forms empty fields to fill in

Type in the essential details in ZIP, Fax, ZIP, YES, NOYES, NO Pharmacy, name NC, PDP NP, IPhone Fax, Q, type, r, days and Dosage, form area.

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