DRUG COVERAGE REQUEST FORM

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                                            DRUG COVERAGE REQUEST FORM
                      Behavioral Health/Medical Management/Pharmacy Services Fax #: 973-0676
                                                       PROVIDER INFORMATION
Prescribing Provider Name:                                                                           Specialty:
Office Contact Person:                                                                       Phone #:                       Fax #:
Pharmacy Name:                                                                               Phone #:                       Fax #:
      (If known)
If Pharmacy is affiliated with a clinic or facility, please indicate facility name:                                    Date of Request:


                                                        MEMBER INFORMATION
Name:                                                                        Member ID #:                                    D.O.B.:
                                                              TYPE OF REQUEST
      Coverage Determination Review                   Coverage Redetermination Review                              Tier Change Review
                 ACA/ACAP                                           ACA/ACAP                                                ACA
    Standard - 72 Hours                               Standard - 7 Calendar Days                            Standard - 72 Hours upon reciept of
                                                                                                                       supporting statement
    Expedited - 24 Hours (*Notate Reason Below)       Expedited - 72 Hours       (*Notate Reason Below)
                   QUEST
    Standard - 14 Calendar Days
    Expedited - 72 Hours   (*Notate Reason Below)

                                                         REASON FOR REQUEST
Diagnosis:
Medication Name:
Strength & Dosage:                                                          # of Refills:          NDC# (if available):
Other Medications tried:


Reason for Exception:


Reason for Expedited Request*:


   Provider Signature:                                                                                                    Date:

FOR ALOHACARE USE ONLY:                       QU          Q-N/Q-A            ACA              ACAP           Determination             Redetermination
     APPROVED            Date Approved:**                        # of Refills:               Approved Through Date:
     NOT APPROVED Date Denied:                             Time:                   Denial Reason:


     Pharmacy Contacted: Date:                        Time:                Name:                                  Processor Initial/Date:
     Provider Contacted:         Date:                Time:                Name:                                  Processor Initial/Date:
     Member Contacted:           Date:                Time:                Name:                                  Processor Initial/Date:
   Reviewer's Signature:                                                                                                  Date:

    PCP:                                  EFF:                                      PREV:                                  TPL:
           PART B       PART D               RX          MM           Formulary              Non-Formulary         Auth Tech:
12/18/08                  **NO PRIOR AUTHORIZATION NUMBER REQUIRED FOR PHARMACY APPROVED REQUESTS.                                                   Ph0022
           Pharmacy: 973-7418 - Pharmacy Toll-Free: 866-973-7418 - Pharmacy Fax: 973-0676 - Pharmacy Toll-Free Fax: 888-667-0680
                       Drug Coverage Request Form Elements
                                             To be used for all AlohaCare Plans

                             REQUESTS WITH MISSING OR INCOMPLETE INFORMATION
                                       WILL DELAY COVERAGE REVIEW

                                          PROVIDER INFORMATION:
Prescribing Provider Name - Prescriber's first and last name.
Specialty - Prescriber's specialty, if applicable.
Office Contact Person - Individual designated by the prescriber and authorized to provide information to AlohaCare staff.
Phone # - Prescriber's office telephone number.
Fax # - Prescriber's office fax number (must be able to accept confidential patient health information).
Pharmacy Name (if known) - Dispensing pharmacy.
Phone # - Pharmacy telephone number.
If pharmacy is affiliated with a clinic or facility, please indicate facility name - Name of the Clinic or Facility with which the
pharmacy has any affiliation.
Date of Request - Date of submission to AlohaCare

                                            MEMBER INFORMATION:
Name - Patient's first and last name.
Member ID# - Patient's AlohaCare member identification number.
DOB - Patient's date of birth.

                                                    TYPE OF REQUEST:
Coverage Determination Review: This section should be used for initial coverage determinations only.
   •      AlohaCare Advantage & AlohaCare Advantage Plus (ACA/ACAP)
          o              Standard determinations are made within 72 hours.
          o              Expedited determinations are made within 24 hours. Per CMS requirements requests will be
                         expedited if supporting evidence is provided demonstrating that the member's life or health will be
                         endangered if a decision is not made within 24 hours.
   •      QUEST
          o              Standard determinations are made within 14 calendar days.
          o              Expedited determinations are made within 72 hours. Per regulatory guidelines requests will be
                         expedited if supporting evidence is provided demonstrating that the member's life or health will be
                         endangered if a decision is not made within 72 hours.

                                             Applicable to ACA/ACAP ONLY.
Coverage Redetermination Review: Used to appeal a previously denied coverage request
   •      Standard redeterminations are made within 7 days.
   •      Expedited redeterminations are made within 72 hours. Per CMS requirements requests will be expedited if supporting
          evidence is provided demonstrating that the member's life or health will be endangered if a decision is not made
          within 72 hours.

Tier Change Review: Used to request a change in prescription copayment level for ACA or ACAP members.
                                                 REASON FOR REQUEST:
Diagnosis - Narrative diagnosis and ICD-9 code (if available) pertaining to the medication being requested.
Medication Name - Name of medication being prescribed.
Strength & Dosage - Medication strength and frequency of administration.
# of Refills - Number of prescription refills being requested
NDC # (if available) - National Drug Code number of medication being prescribed.
Other Medications Tried - List of ALL medications attempted and failed in the patient's lifetime pertaining to the medication being
requested.
Reason for Exception - Provide clinical justification to substantiate the exception request. Supporting clinical journal articles,
paper abstracts can be faxed along with the Drug Coverage Request Form when the medication is not widely used for
the diagnosis provided.
Reason for Expedited Request - Provide clinical justification indicating threat of serious harm to patient's life or health to
substantiate an expedited request
Provider Signature - Prescriber's signature.
Date - Date of Prescriber's signatureText




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