Get Integral Quality Care Pharmacy Coverage Determination Request Form 2003-2025

Filling out the Integral Quality Care Pharmacy Coverage Determination Request Form online is a straightforward process. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to access the form and open it in your editing interface.
2. Begin by filling out the patient information section, which includes the patient’s name, member ID number, date of birth, and contact information.
3. Next, complete the prescriber information section. Include the prescriber’s name, NPI number, office phone and fax numbers.
4. In the diagnosis and medical information section, specify the medication, its strength, route of administration, frequency, and whether it is a new prescription or if therapy has already begun. Also indicate the expected length of therapy and quantity needed.
5. Add additional details including the patient's height, weight, diagnosis, ICD9 code, and any known allergies.
6. The prescriber must provide their signature and the date to validate the request.
7. Make sure to thoroughly fill out the rationale for the exception request or prior authorization, selecting the appropriate checkboxes and providing detailed explanations as required.
8. Once all sections are completed, ensure that all supporting medical records and documentation are attached.
9. Finally, save your changes, and decide whether to download, print, or share the completed form.

Take action now by filling out the Integral Quality Care Pharmacy Coverage Determination Request Form online.