Get 62894 Na Ccp/pdp 2015 Pharmacy Coverage Determination Request Form

Completing the 62894 NA CCP/PDP 2015 Pharmacy Coverage Determination Request Form is an essential step to ensure that your medication needs are addressed. This guide provides step-by-step instructions on how to accurately fill out the form online, helping you navigate the necessary fields with ease.

Follow the steps to successfully complete your request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Identify who is making the request by selecting one of the options: Provider, Member, or Appointed Representative. If selecting Appointed Representative, ensure to include a signed Appointment of Representative form (CMS-1696) or equivalent notice.
3. Indicate if you are requesting an expedited review by checking the expedited box. This certifies that applying the standard review timeframe may jeopardize the member’s health or ability to regain maximum function.
4. Complete the required fields marked with an asterisk. This includes Member Name, WellCare ID number, Date of Birth, Date of Request, Physician's Full Name/Specialty, Member’s Telephone Number, Physician Signature, Diagnosis of Requested Medication, Contact Name at MD Office, Physician Phone Number, Physician NPI, Pharmacy Name, Pharmacy Phone Number, Medication, Strength, and Route of Administration, Frequency, Physician Fax Number, Quantity, Duration of Therapy, and Drug Allergies.
5. If the medication is for a transplant drug, indicate whether the transplant was covered by Medicare by selecting 'Yes' or 'No'.
6. If the member is a hospice patient, specify if the medication is related to the terminal condition by selecting 'Yes' or 'No'.
7. Select the type of coverage determination request by checking the applicable box for Prior Authorization, Non-Formulary Exception, Step Therapy Formulary Exception, Quantity Limit Formulary Exception, or Tiering Exception. Provide the necessary clinical information or rationale for your request as per the selected type.
8. Once all fields are completed and verified for accuracy, save your changes. You may then download, print, or share the form as needed.

Take the next steps to complete your coverage determination request online today.