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 med....
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How to fill out the UPMC CMN12-0201-2K online
The UPMC CMN12-0201-2K form is essential for members seeking an exception to their pharmacy benefit limit. This guide provides clear, step-by-step instructions to help you fill out this form accurately and efficiently online.
Follow the steps to complete the UPMC CMN12-0201-2K form online.
- Click the ‘Get Form’ button to access the form and open it in the editor.
- Begin by filling out the 'Office Contact' section. Include the provider's specialty, first name, last name, phone number, and fax number.
- In the 'Patient Information' section, enter the patient’s name, UPMC Health Plan ID number, date of birth, and age. Then, specify the drug requested, its strength, frequency, expected duration of therapy, and select whether it is a new or ongoing medication.
- Provide the 'Provider NPI#', quantity to be dispensed, number of refills, and directions for use. If the medication is ongoing, include the start date and indicate whether the member has responded to therapy.
- Check the applicable criteria that support the need for the medication, detailing the patient's diagnosis and providing a narrative that explains the medical necessity. Attach any supporting documentation from the medical record.
- List all medications the member is currently taking that relate to the stated diagnosis, including drug name, strength, and frequency.
- Indicate if the prescription requires prior authorization and include any necessary supporting documentation.
- Finally, affix the prescriber's signature and date the form to complete the submission.
- Once all fields are filled out correctly, save your changes, and consider the options to download, print, or share the completed form.
Complete your UPMC CMN12-0201-2K form online today to ensure timely processing of your request.
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