Edit, Download, and Sign the Medication Request Form Prior Authorization
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How do I fill this out?
Filling out the Medication Request Form is an important step in obtaining coverage for specific medications. To begin, ensure all patient and drug information are accurate and complete. Follow the detailed instructions provided to assist you in completing the form correctly.
How to fill out the Medication Request Form Prior Authorization?
1
Complete all patient information fields.
2
Provide the requested drug name, dose, and form.
3
Fill in the prescriber's information including name, NPI, and contact details.
4
Check the applicable exception types and attach necessary documents.
5
Sign the form and fax it to Health New England Pharmacy Services at 413-233-2777.
Who needs the Medication Request Form Prior Authorization?
1
Physicians needing prior authorization for patient medications.
2
Pharmacy providers requesting medication coverage exceptions.
3
Patients seeking coverage for new-to-market or compounded medications.
4
Medical offices managing Step Therapy exceptions.
5
Specialists requiring exemptions for multi-source brand prescriptions.
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What are the instructions for submitting this form?
Complete the form with all required patient, drug, and prescriber information. Attach any necessary documentation. Fax the completed form to Health New England Pharmacy Services Department at 413-233-2777. For any questions, contact Health New England Member Services Department at (800) 310-2835. For Medicare Part D requests, visit www.hne.com/medicare for more information. Ensure all information is accurate to prevent delays in processing.
What is the purpose of this form?
The purpose of the Medication Request Form is to facilitate the process of obtaining coverage for specific medications that require prior authorization. By providing all necessary patient, prescriber, and drug information, this form helps healthcare providers ensure that their patients have access to the medications they need. Health New England uses the completed form to process requests efficiently, preventing delays in patient care.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for patient name, HNE ID#, date of birth, and allergies.
- 2. Drug Information: Fields for the requested drug name, dose/strength/form, and duration of requested treatment.
- 3. Prescriber's Information: Includes prescriber's printed name, NPI number, office phone, contact name, signature, and other pertinent details.
- 4. Type of Exception: Checkboxes to indicate the specific type of exception being requested, such as quantity limitation or step therapy.
- 5. Reason for Discontinuation: Field to describe the reason for discontinuing previous medications and their past failures.
What happens if I fail to submit this form?
If you fail to submit the Medication Request Form, your request for prior authorization may be delayed or denied. This can result in patients not receiving the necessary medication on time.
- Delayed Medication Coverage: Failing to submit the form may delay processing and approval of the medication request.
- Denial of Coverage: Incomplete or missing forms can lead to denial of the prior authorization request.
How do I know when to use this form?
- 1. Prior Authorization: When a medication requires approval before it can be covered.
- 2. Step Therapy Exception: To request coverage for a medication after a step therapy failure.
- 3. Quantity Limit Exception: When a patient needs a quantity exceeding the standard limit.
- 4. New-to-Market Drug: To request coverage for newly available medications.
- 5. Compounded Medication: For medications compounded from multiple ingredients.
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How do I complete the patient information section on the form?
Enter the patient's name, HNE ID#, date of birth, and any allergies in the designated fields.
What information is needed for the drug requested?
Provide the requested drug name, dose/strength/form, and the duration of requested treatment.
How do I submit the completed Medication Request Form?
Sign the form and fax it to the Health New England Pharmacy Services at 413-233-2777.
