DX 6450 Pharmacy Authorization Form

User Manual: DX 6450

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Pharmacy Authorization / Exception Form
Customer Service

Type of Request:
Prior Authorization
Non-Formulary Medication
Quantity Limit Exception
Step Therapy Exception
Tiering Exception

Toll Free: 1.844.522.5282
TDD Relay: 1.800.955.8771
6450 US Highway 1
Rockledge, FL 32955
Additional copies of this form can be found in our public website located at: myHFHP.org

FAX COMPLETED FORM AND SUPPORTING DOCUMENTATION TO:

1.855.328.0061

Important: If previous coverage
determination was Denied, please follow the
Appeals Process located in our secure
provider portal located at: myHFHP.org/login

Failure to complete this form in its entirety, including: Rationale for Exception Request,
Required Explanation, and supporting clinical documentation, may result in delayed processing
or an adverse determination for insufficient information.
Step 1:
Patient &
physician
information

Step 2:
Diagnosis
and
Medical
Information

Patient Information

Requesting Physician Information

First Name:_____________________________________

Physician Name: _______________________________________________

Last Name:_____________________________________

Contact Person: _______________________________________________

DOB: _______/_________/____________

Phone: (______) ____________________________ Ext._______________

Health First ID #: :________________________________

Fax: (_______) ________________________________________________

Drug Name:

Strength & Route of Administration:

Qty:

HCPCS Code:

Expected Length of Therapy:

Dosage/ Frequency:

Place of Service:
 Member picking up at the Pharmacy
 Physician is Buying and Billing

Drug Allergies (if applicable):
Diagnosis related to request:__________________________________________
ICD dx Code: ________________________________________________________

Step 3:
Rationale for
Exception
Request or
Prior
Authorization

*Attach Supporting Clinical Notes*
 Alternate drug(s) contraindicated or previously tried, but with adverse outcome (e.g., toxicity, allergy, or therapeutic failure)
 Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of
therapy on each drug(s);
 Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on
current drug(s); high risk of significant adverse clinical outcome with medication change;
 Specify below: Anticipated significant adverse clinical outcome;
 Other: Explain below;
REQUIRED EXPLANATION: _______________________________________________________________________________________
_______________________________________________________________________________________________________________

 Please check here if the patient is receiving this medication as part of a clinical trial

Request for Expedited Review
EXPEDITED REVIEW TIMEFRAME IS 24 HOURS.
CRITERIA FOR EXPEDITED REVIEW: IF WAITING FOR A DECISION IN THE STANDARD TIMEFRAME COULD SERIOUSLY HARM THE MEMBER’S
LIFE, HEALTH OR ABILITY TO REGAIN MAXIMUM FUNCTION, YOU CAN ASK FOR AN EXPEDITED (FAST) DECISION.
CHECK HERE IF YOU ARE REQUESTING A FAST DECISION THAT MEETS THE CRITERIA ABOVE:
USE OF THIS FORM DOES NOT GUARANTEE ELIGIBILITY OF COVERAGE AND DOES NOT SUPERCEDE ANY MEMBER BENEFIT PLAN
LIMITATIONS OR THE PROVIDER’S CONTRACTUAL LIMITATIONS.
CONFIDENTIALITY: The information contained in this facsimile message may be legally privileged and confidential information intended only for the use of the
individual or entity named above. If the reader is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this telecopy
is strictly prohibited. If you have received this telecopy in error, please immediately notify the sender above and return the original message to us at the address
above by the United States Postal Service. Thank you for your cooperation.
AFFIRMATIVE STATEMENT: UM decision making is based only on appropriateness of care and service and existence of coverage.
Health First Health Plans does not reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for UM decisionmakers do not encourage decisions that result in under-utilization.
Health First Commercial Plans, Inc. and Health First Insurance, Inc., are both doing business under the name of Health First Health Plans. Health First Health
Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration
of the plan, including enrollment and benefit determinations.
27357-77150_MPINFO203 (07/16)
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