Get Md Physicians Care Pharmacy Coverage Determination Request Form 2019-2025

Filling out the MD Physicians Care Pharmacy Coverage Determination Request Form online can be a straightforward process when you understand each section. This guide will walk you through the essential steps needed to accurately complete the form, ensuring a smoother submission for your coverage determination request.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and load it in your preferred editor.
2. Begin by entering the patient name in the designated field, followed by the prescriber name. Make sure to include the member ID number and prescriber NPI number.
3. List any known allergies in the relevant field. If there is a servicing provider, include their name and NPI number.
4. Document the medication, strength, and dosage in the specified fields, along with the route of administration. Indicate if this is a new therapy or a continuation by selecting the appropriate option and providing the dates as required.
5. State the diagnosis for medication treatment and provide directions for usage along with the expected length of therapy and the corresponding ICD10 code.
6. Ensure the prescriber’s signature and date are provided, as this is mandatory for the request to be valid.
7. Select whether the medication will be obtained through the medical benefit or the pharmacy benefit, filling in the necessary information such as J-code or quantity and total billable units.
8. Provide rationale for the exception request or prior authorization by attaching the supporting clinical notes and detailing any reasons for alternative covered drugs that were contraindicated or had adverse outcomes.
9. After completing all sections, review the form for any errors. You can then save your changes, download, print, or share the completed form as needed.

Start filling out your MD Physicians Care Pharmacy Coverage Determination Request Form online today for a seamless submission process.