Get Gateway Health Plan Medicare Assured Hmo Snp Drug Exception Form

The Gateway Health Plan Medicare Assured Hmo Snp Drug Exception Form is essential for requesting coverage of nonformulary medications. This guide will walk you through filling out the form online, ensuring you provide all necessary information for a successful request.

Follow the steps to complete the drug exception form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the Member ID number as it appears on the member's card.
3. Provide the Member Name and Date of Birth in their respective fields.
4. Fill in the Pharmacy Name and Pharmacy Phone number for the location that will process the prescription.
5. Document the Drug Name that is being requested for coverage.
6. Indicate the Dosage and Frequency of the requested drug.
7. State the Diagnosis for which the drug is prescribed, providing as much detail as necessary.
8. List any formulary alternatives that have previously been used by the patient, including the Drug Name, Strength, and Dates Used.
9. Provide documentation on the failure of therapy or adverse reactions from formulary alternatives, explaining why the requested drug is necessary.
10. If applicable, include any Additional Clinical Information that may support the request.
11. Print the Physician Name, provide their phone number, and have the physician sign and date the form.
12. Decide if the member's health could be at serious risk by waiting three days. If yes, follow the provided instructions for expedited review.
13. Once all fields are complete, review the form for accuracy. Users can then save changes, download, print, or share the form as needed.

Complete your Gateway Health Plan Medicare Assured Hmo Snp Drug Exception Form online today for a seamless request process.