PEEHIP MedImpact Drug Formulary Guidelines
This document outlines guidelines for selecting and evaluating medications for PEEHIP members. It serves as a comprehensive resource for drug safety, efficacy, and cost-effectiveness. Physicians and pharmacists can utilize this formulary for optimal patient care.
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How do I fill this out?
To fill out this form, gather all necessary patient information and ensure you understand the specific requirements for medication requests. Read through the guidelines carefully to determine if a non-formulary drug is necessary. Complete each section of the form accurately before submission.
How to fill out the PEEHIP MedImpact Drug Formulary Guidelines?
1
Gather patient health plan information and ID number.
2
Fill out the patient's details including diagnosis and medication requested.
3
Indicate the dosage and reason for medication request.
4
Provide physician and pharmacy contact information.
5
Fax or send the completed form to MedImpact for review.
Who needs the PEEHIP MedImpact Drug Formulary Guidelines?
1
Physicians need this form to request non-formulary drugs for patients.
2
Pharmacists require this form to ascertain coverage for specific medications.
3
Healthcare providers need this form for obtaining prior authorizations.
4
Patients may need this form if their prescribed medication is non-formulary.
5
Insurance coordinators require this form to verify medication coverage details.
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What are the instructions for submitting this form?
To submit the completed form, fax it to MedImpact at (877) 606-0728 or call (800) 347-5841 for further assistance. Ensure that all required fields are filled out accurately. Submissions can also be made via mail to the address listed on the form for physical documentation.
What are the important dates for this form in 2024 and 2025?
Key dates for the PEEHIP formulary and medication requests will be outlined as needed for 2024 and 2025. It is essential to adhere to submission deadlines and review dates for medication evaluations. Keep informed on any updates from MedImpact regarding formulary changes.
What is the purpose of this form?
The purpose of this form is to facilitate coverage requests for non-formulary medications that may be necessary for patient care. This document serves as a crucial tool for healthcare providers to communicate medication needs effectively. It enhances the process of obtaining prior authorization for essential pharmaceuticals under PEEHIP.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient is required.
- 2. Patient ID: The health plan identification number is mandatory.
- 3. Diagnosis: A clear diagnosis or reason for medication is essential.
- 4. Drug Requested: Specify the medication being requested for coverage.
- 5. Physician Details: Information about the prescribing physician, including contact info.
What happens if I fail to submit this form?
If the form is not submitted correctly, the request for medication coverage may be delayed or denied. Missing information can lead to back-and-forth communication, prolonging the approval process.
- Incomplete Information: Missing patient or medication details may result in rejection.
- Lack of Supporting Documentation: Not providing required medical necessity documents can hinder approval.
- Submission Errors: Errors in faxing or emailing the form can delay processing.
How do I know when to use this form?
- 1. For Non-Formulary Medications: Use this form when a prescribed medication is not on the formulary.
- 2. For Prior Authorization Requests: Required for medications that need pre-approval before dispensing.
- 3. When Documenting Specific Patient Needs: Facilitates detailing the clinical necessity for the requested medication.
Frequently Asked Questions
How can I edit this formulary PDF?
You can edit the PDF by opening it in PrintFriendly and modifying the text fields directly.
Is it easy to fill out the medication request on this form?
Yes, the form is structured for clarity, making it user-friendly for quick completion.
What should I do if my medication is non-formulary?
You can submit a request using this form to seek coverage approval for non-formulary medications.
Can I save changes to the PDF?
You can download the edited PDF but cannot save directly within the PrintFriendly interface.
Where do I send my completed request?
Completed requests can be faxed to MedImpact at the number provided on the form.
What information do I need to provide?
You need to provide patient details, medication requested, and physician information.
How long does the approval process take?
The approval process timeline can vary, but you will receive an authorization number for approved requests.
What if my request is denied?
You can appeal the denial by providing additional medical necessity information.
Is there a fee for processing this request?
There is typically no fee for the request submission itself, but check your insurance profile.
Can I request a medication for my child?
Yes, the form can be used to request coverage for medications for dependents.
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