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FOR INTERNAL USE ONLY Contacted: Approved: Physician: Denied: Attn: Prior Authorization Department Pharmacy: Returned: 10181 Scripps Gateway Court San Diego, CA 92131 Phone: (800) 347-5841 Patient: ID # Fax: (877) 606-0728 Medication Request Form MedImpact Healthcare Systems, Inc. Instructions: This form is to be used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is no suitable alternative available. Please complete this form and fax to Medlmpact Healthcare Systems, Inc. at (877) 606-0728 or please call (800) 347-5841 with this information. If you have any questions regarding this process, please contact Medlmpact's Customer Service at (800) 347-5841. Review Criteria: The following guidelines are used in reviewing medication requests: 1. The use of Formulary Drug Products is contraindicated in the patient. 2. The patient has failed an appropriate trial of Formulary or related agents. 3. The choices available in the Formulary are not suited for the present patient care need and the drug selected is required for patient safety. 4. The use of a Formulary Drug Product may provoke an underlying medical condition, which would be detrimental to patient care Medication Request Information (please complete each section of this form prior to transmittal): PATIENT NAME (REQUIRED): PATIENT'S HEALTH PLAN (REQUIRED): PATIENT ID # (REQUIRED): PHYSICIAN NAME/SPECIALTY: PATIENT HEIGHT AND WEIGHT (REQUIRED): PHYSICIAN ID#/DEA#: PATIENT DOB (REQUIRED): PHYSICIAN AREA CODE AND TELEPHONE NUMBER: DIAGNOSIS (REQUIRED): PHYSICIAN AREA CODE AND FAX NUMBER (REQUIRED): PHARMACY USED BY MEMBER: PHARMACY AREA CODE AND TELEPHONE NUMBER: DRUG REQUESTED: QUANTITY (PER MONTH): DOSE: LENGTH OF TREATMENT (PLEASE BE SPECIFIC): STRENGTH: DOSAGE FORM (e.g.• ORAL, INJECTION): REASON FOR MEDICATION REQUEST (PLEASE BE SPECIFIC, GIVE DETAIL): OTHER MEDICATIONS TRIED AND/OR FAILED (PLEASE BE SPECIFIC, GIVE DETAIL INCLUDING REASON FOR FAILURE): OTHER PERTINENT HISTORY (RELATIVE OR PERTAINING TO THIS REQUEST): PROVIDER NAME AND SIGNATURE: W,/W WĂŐĞϯŽĨϭϱϮ Commercial Formulary Drug Name Tier Requirements/Limits ALLERGY ALLERGENIC EXTRACTS,