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Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above.  \nPlease note any information left blank or illegible may delay the review process.  \n\n| Patient Name: | Prescriber Name: |  |\n| --- | --- | --- |\n| Member/Subscriber Number: | Fax: | Phone: |\n| Date of Birth: | Office Contact: |  |\n| Group Number: | NPI: | State Lic ID: |\n| Address: | Address: |  |\n| City, State ZIP: | City, State ZIP: |  |\n| Primary Phone: | Specialty/facility name (if applicable): |  |\n\n*Please note that MedImpact will process the request as written, including drug name, with no substitution.  \nDrug Name and Strength:  \nDirections / SIG:  \nExpedited / Urgent  \nPlease attach any pertinent medical history or information for this patient that may support approval. Please answer the following questions and sign.  \n\n| Q1: Is this request for initial or continuing therapy?\u003Cbr> Initial therapy  Continuing therapy |\n| --- |\n| Q2: If the request is for CONTINUING THERAPY, please provide the start date (MM/YY): |\n| Q3: Please indicate the patient’s diagnosis for the requested medication: |\n| Q4: Please list all other medications the patient has previously tried for the indicated diagnosis along with the dates and outcomes\u003Cbr>(e.g. ineffective, adverse reaction, etc): |\n| Q5: Please provide any supporting clinical statements such as chart notes, lab values, adverse outcomes, treatment failures, or any\u003Cbr>other additional clinical information to support an authorization request (if needed): |\n\n1 Copyright © 2024 MedImpact Healthcare Systems, Inc. All rights reserved. E1 2024  \n| Q6: IF the request is for a compounded product, please check all that apply: |  |  |  |\n| --- | --- | --- | --- |\n| | The prescriber attests that the requested compounded product contains at least ONE prescription ingredient The prescriber attests that the requested compounded product is not a copy of a commercially available FDAapproved product\u003Cbr>Dosage form being compounded is due to the patient being unable to use the commercially available product Patient is unable to use a commercial available product due to a hypersensitivity or allergy to any of the components (i.e. dyes, preservatives, fragrances, gluten) | | There is a commercially available product shortage or discontinuation by the manufacturer\u003Cbr>The requested compounded product contains bulk powders\u003Cbr>The requested compounded product contain ONLY overthe-counter ingredients\u003Cbr>The request is for a renewal and the prescriber attests that patient has had disease stabilization or improvement with the use of this compounded product\u003Cbr>None |\n| Q7: IF the request is for a compounded product, please specify if the unique dosage form is considered standard of care based on\u003Cbr>credible scientific literature defined as one of the following (Check all that apply):  Peer reviewed literature indexed in Medline\u003Cbr> CMS recognized pharmacy compendia (e.g. NCCN, DrugDex, and AHFS DI)\u003Cbr> Published clinical practice guidelines developed by multidisciplinary experts and clinicians affected by the guidelines (e.g. American Medical Association, Infectious Disease Society of America)\u003Cbr> Other\u003Cbr> None of the above |  |  |  |\n| Q8: If answer is OTHER, please specify below: |  |  |  |\n| Q9: Coverage Policy: The Plan provides coverage only for medications that it defines or determines to be used for medically accepted indications. MedImpact will approve requests based on the criteria outlined in this paragraph and the Plan’s Benefit Design if the medication and quantity prescribed are covered by the plan and being used for a medically accepted indication. Medically accepted indications are defined by the plan as: Any use of a drug which i","cbCaiqdRVgcloYWz","https://ap.wps.com/l/cbCaiqdRVgcloYWz","pdf",136216,"English","# Coverage Determination Request Details\n## Patient and Prescriber Information\n## Drug Information and Therapy Type\n## Clinical Questions (Q1-Q5)\n## Compounded Product Questions (Q6-Q8)\n## Coverage Policy Criteria","[{\"question\":\"Where should the completed form be sent, and what happens if fields are blank or illegible?\",\"answer\":\"Fax the form to the listed fax-back number. Information left blank or illegible may delay the review process.\"},{\"question\":\"What details are required about the medication and therapy request?\",\"answer\":\"Provide drug name and strength, directions/SIG, indicate expedited/urgent status, and specify whether it is initial or continuing therapy with the start date for continuing therapy.\"},{\"question\":\"What must be included to support medical necessity and authorization approval?\",\"answer\":\"Include the patient’s diagnosis, all previously tried medications with dates and outcomes, and supporting clinical statements such as chart notes, lab values, adverse outcomes, and treatment failures.\"}]","Coverage Determination Request Form - EOC ID Medically-Accepted Indication Prior Authorization - Fax Back | PDF",1789632318]