Get UPMC CMN12-0201-2K 2012-2024

UPMC for You Medical Assistance ONLY Pharmacy Benefit Limit Exception Request Form IF THIS IS AN URGENT REQUEST Please Call UPMC Health Plan Pharmacy Services. Otherwise please return completed form to UPMC HEALTH PLAN PHARMACY SERVICES PHONE 800-979-UPMC 8762 FAX 412-454-7722 PLEASE TYPE OR PRINT NEATLY Certain UPMC for You members have limited benefits and are subject to a six 6 prescription per calendar month benefit limit. If you feel an exception to this benefit limit is necessary please complete the following information. Please complete all sections of this form AND include details of past relevant medical treatment and diagnoses which substantiates the need for an exception. Incomplete responses may delay this request. Use one form per each medication requested* Office Contact Provider Specialty Provider First Name Provider Last Name Provider Phone Provider Fax Patient Name Drug Requested Patient UPMC Health Plan ID Number Strength Frequency Expected Duration of Therapy New medication Ongoing medication Provider NPI Patient DOB Patient Age Quantity Dispensed Refills Directions If ongoing provide date started If medication is ongoing did the member respond to therapy Yes No Please check all criteria that apply and provide the member s diagnosis and a narrative explaining the medical need for this medication and provide supporting documentation from the medical record 1. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the patient. 3. Granting the exception is a cost-effective alternative for UPMC for You. Diagnosis Narrative Please list the medications the member is currently taking related to the above diagnosis Drug Name Please provide any additional clinical information to support the need for this medication Is this a prescription for a medication that requires prior authorization Yes No If yes submit the documentation to support a request for prior authorization Prescriber Signature Date CMN12-0201-2K FINAL rev 6-4-12 MA Pharm*BLE FM C20120326-11. Use one form per each medication requested* Office Contact Provider Specialty Provider First Name Provider Last Name Provider Phone Provider Fax Patient Name Drug Requested Patient UPMC Health Plan ID Number Strength Frequency Expected Duration of Therapy New medication Ongoing medication Provider NPI Patient DOB Patient Age Quantity Dispensed Refills Directions If ongoing provide date started If medication is ongoing did the member respond to therapy Yes No Please check all criteria that apply and provide the member s diagnosis and a narrative explaining the medical need for this medication and provide supporting documentation from the medical record 1. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the patient. Patient has a serious chronic systemic illness or other serious health condition and denial of the exception will jeopardize the life of the patient. 3. Granting the exception is a cost-effective alternative for UPMC for You. Diagnosis Narrative Please list the medications the member is currently taking related to the above diagnosis Drug Name Please provide any additional clinical information to support the need for this medication Is this a prescription for a medication that requires prior authorization Yes No If yes submit the documentation to support a request for prior authorization Prescriber Signature Date CMN12-0201-2K FINAL rev 6-4-12 MA Pharm*BLE FM C20120326-11. .