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Universal Pharmacy Medical

Review Request Form

***Only complete forms can be processed. Incomplete forms may result in an administrative denial due to lack of information***

PATIENT INFORMATION PRESCRIBER INFORMATION

Name: ________________________________ Date: _________________ Name: _____________________________ Specialty: _______________________

DOB: ______________ Member THP ID: ____________________________ Provider ID: _______________________ Phone: ___________________________

Fax: _____________________ Office Contact: _____________________________

Diagnosis: ___________________________________________________

Relevant Co-morbid Diagnoses: ___________________________________

Prescriber Signature (required): _______________________________________

Additional Comments:

____________________________________________________________ Tier exception request (Tufts Medicare Preferred ONLY): ___Yes ___ No

Please specify reason(s) for request:

____________________________________________________________

_____ Formulary/Preferred drug(s) contraindicated or tried and failed, or not as

effective as requested drug

REQUESTED DRUG INFORMATION

_____ Therapeutic failure or not as effective; please indicated length of therapy of

Type of Program Override Request (check one): each applicable drug and adverse outcome

____ Dispensing Limitation ____ Non-covered Drug _____ Other; please explain below

____ Step Therapy ____ Prior Authorization Explanation:___________________________________________________________

_____________________________________________________________________

Drug Name/Strength/Dosage Form: _________________________________

Antifungals (itraconazole (Sporanox), Penlac, terbinafine (Lamisil), etc.)

Duration of requested treatment: ________________________________________ Does the patient have uncomplicated onychomycosis? ____Yes* ____ No

1. Limited to nail surface? ___Yes ___ No

Reason for Coverage Request (check one):

2. Lunular involvement? ___ Yes ___ No

_____ Treatment failure (drug(s)): ___________________________________

3. Does the patient have a medical contraindication to oral antifungal therapy

_____ Adverse reaction (drug(s)): ___________________________________

(Penlac only): ___Yes (explain)_______________________ No ___

_____ Other clinical reason(s): _____________________________________

4.Check all that apply:

Duration of treatment with failed drug(s): _______________________________ ____ Paronychia ____ Diabetes Mellitus

____ Systemic Fungus ____ Immune Suppression

Aranesp, Epogen, Procrit (Tufts Health Plan Medicare Preferred ONLY) ____ Peripheral Vascular Disease ____ None

____ Medically significant pain (Office notes required)

Is this being used to treat anemia in a patient with ___ Yes ___ No

* Any request for coverage with a diagnosis of uncomplicated onychomycosis will be

chronic renal failure that undergoes dialysis

denied as a benefit exclusion

Fax/Mail completed forms to: Tufts Health Plan Precertification Department, 705

Drug List and Clinical Criteria available online at: www.tuftshealthplan.com

Mount Auburn Street, Watertown, MA 02472

Fax: 617-***-****

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