Get Quantity Limit Exception Form Ssi2013

Filling out the Quantity Limit Exception Form SSI2013 online is a straightforward process that allows users to request coverage for medications exceeding established quantity limits. This guide will walk you through each section of the form, ensuring you have the necessary information to submit a complete request.

Follow the steps to complete the form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
2. Begin with the Patient Information section. Fill in the patient's name, member ID, Medicare ID, date of birth, sex, address, city, state, ZIP code, and phone number. Indicate whether the patient is a nursing home resident or a home care patient.
3. Proceed to the Prescriber and Pharmacy Information section. Provide the prescriber’s name, specialty, DEA, NPI, address, city, state, ZIP code, phone number, and fax number. Next, enter the pharmacy’s name, NCPDP, NPI, phone number, and fax number.
4. In the Information for Requested Drug section, specify the drug name, circle whether it is brand or generic, and provide the drug's strength and dosage form. Indicate the quantity per 30 days and whether it is a new prescription or a refill. Include specific directions, diagnosis, and ICD-9 code.
5. Complete the Request for Quantity Limit Exception Criteria section. Provide medical justification for the request, detailing why the requested quantity is necessary, and include any relevant previous treatment experiences that were ineffective.
6. If applicable, specify any clinical concerns relating to the drug regimen that affects its effectiveness or patient compliance. If the requested medication has not been previously trialed, check the designated box.
7. Finally, attest that the information provided is true and accurate as of the current date. The prescriber should sign and date the form.
8. Once all sections are complete, save the changes to the form. You can then download, print, or share your completed submission as needed.

Take the necessary steps today to complete and submit your Quantity Limit Exception Form online.