Pharmacy Benefit Exception Request Form - Neighborhood Health Plan Of Ri
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1Neighborhood Health Plan Of RI
Pharmacy Benefit Exception Request Form for patients
covered under the “generic first” benefit
Lupron® (Leuprolide Acetate)
Gonadotropin Releasing Hormone Agonists (GnRH)
Instructions:
The General laws of the State of RI provide for a “generic first” Pharmacy Benefit for the State’s Managed Medicaid program. Use of brand name drugs is
limited to specific “exempt” drug classes and cases where there is documented evidence that the patient has tried and failed therapy with generic drugs. This
form is to be used by participating physicians and providers to obtain coverage for a brand name drug when there is evidence that the patient has tried and
failed therapy with generic drugs. Failure to complete this form will result in Neighborhood not paying for the ordered drug and may delay delivery of the drug
to your patient.
Please complete this form and fax to: Neighborhood Customer Service at fax # 866-423-0945.
Please complete the following information:
Date of Request: ____/_____/_____
Prescriber Name:
(required)
______________________
Member Name:
(required)
Address
(required)
______________________________
City_______________________________ Zip_________
Member ID Number, otherwise SSN#:
(required)
Prescriber Specialty:
(required)________________________________________
Tel # & extension:
(required)
(
) -
Member Date of Birth:
(required)
Office Fax Number:
(required)
(
) -
Member Sex: M
F
(Circle One)
Contact Person at Office:
Medication requested: _________________________________________________ Strength: ____________________
Quantity: _________ Day Supply ______Directions: _______________________________________________________
Criteria is driven by diagnosis. Please fill out the appropriate box below:
Endometriosis (Initial Therapy)
Previous medications used:
Drug_____________________________________Dates of therapy_______________
Ineffective
Not Tolerated
(circle one)
Drug_____________________________________Dates of therapy_______________
Ineffective
Not Tolerated
(circle one)
Drug_____________________________________Dates of therapy_______________
Ineffective
Not Tolerated
(circle one)
Endometriosis (Renewal)
This is a renewal request (all requests for this diagnosis will be approved for 6 months)
For renewal requests, please indicate specific case details_______________________________________________________
______________________________________________________________________________________________________
Uterine Fibroids with vaginal bleeding (Initial Therapy
)
(requests for this diagnosis will be approved for 1 month at a time, maximum 3 months of
therapy)
Member has Iron deficiency anemia with hemoglobin <10g/dL despite compliance with oral iron therapy (OTC Iron is a
covered benefit as long as it is presented to the pharmacist on a prescription).
Renewal request
Member continues to have iron deficiency anemia with hemoglobin <10g/dL despite compliance with oral iron therapy
Central Precocious Puberty with onset of secondary sexual characteristics earlier than age 8 for females or age 9 for
males
Diagnosis is confirmed by a pubertal response to GnRH stimulation test
Bone age advanced 1 year beyond chronicle age
Presence of tumor has been ruled out
Prostate Cancer
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any falsification, omission,
or concealment of material fact may subject me to civil or criminal liability.
Prescriber’s Signature___________________ __ ____________
NPI ________________
Date________________
For updated Neighborhood pharmacy information, please supply email address ________________________________
Completed form must be faxed to Neighborhood Customer Service at fax # 866-423-0945.
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