Get Medication Exception Request Form Commercial - Avmed - Avmed

This guide will assist you in completing the Medication Exception Request Form Commercial from AvMed. By following these simple steps, you can ensure that all necessary information is accurately provided to facilitate the medication exception request process.

Follow the steps to fill out the Medication Exception Request Form.

1. Click ‘Get Form’ button to download the Medication Exception Request Form and open it for editing.
2. Fill in the date of submission at the top of the form.
3. In the Patient Information section, enter the Member ID, Date of Birth, and provide the Member Name. Indicate if the member is pregnant, and specify their Height and Weight.
4. Provide the Diagnosis and the corresponding Diagnosis (ICD-10) Code in the respective fields.
5. In the Delivery – Administration Information section, select the method of medication delivery, such as in-office administration, retail pharmacy pickup, or home health provider.
6. If applicable, fill in the Facility/Suite information including the Facility/Suite Name and Provider Number.
7. In the Additional Medication Information section, enter the Drug Name, Quantity, Directions for Use, and specify if it is a New Therapy or Continuation of Therapy, including the member's therapeutic response if applicable.
8. Indicate the Duration of Therapy and provide the Procedure Code and Reason for Request.
9. Complete the Physician Information section by entering the Prescriber Name, Specialty, and contact details including the Office Number and Fax Number.
10. After completing the form, review all provided information for accuracy. Upon confirmation, save any changes you've made, and you may choose to download, print, or share the form.

Take a moment to complete your Medication Exception Request Form online and ensure you provide the right information for your needs.