Members can register and login to our Pharmacy Benefit Manager (PBM) system by going to Ingenio-rx.com.This site allows members to search for pharmacy locations, price pharmacy claims, order mail order refills, determine generic availability for a drug, lookup drug interactions and side effects. Browse commonly requested forms to find and download the one you need for various topics including pharmacy, enrollment, claims and more. Page2of%2% New%08/13% PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Patient Name: ID#: Instructions: Please fill out all applicable sections on both pages completely and legibly.Attach any additional documentation that is important for the review, e.g. Alle Produktinformationen anzeigen. It does not include medications that … We must follow Medicare rules in making these changes. Tier 1: These are typically generic drugs that offer the lowest-out-of-pocket costs and greatest value compared to other medications that treat the same condition. Your go-to resource is the Wellmark Drug List. In TX, services provided by Ingenio, Inc. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Formulary Exception/Prior Authorization Request Form Patient Information Prescriber Information Patient Name: DOB: Prescriber Name: Patient ID#: Address: Address: City: State: Zip: City: State: Zip: Office Phone #: Office Fax #: Home Phone: Gender: M or F Contact Person at Doctor’s Office: Diagnosis and Medical Information Browse commonly requested forms to find and download the one you need for various topics including pharmacy, enrollment, claims and more. This process allows us to check ahead of time whether services meet criteria for coverage by a member’s health plan. The Wellmark Drug List gives the drug name, category, tier and what special authorization is required for all the prescription drugs our plans cover. You and your doctor have the right to ask for exceptions to the limits of your drug plan. Step therapy promotes using the most clinically and cost-effective medication(s) as the first step in treating certain health conditions before trying an equally effective, but more costly medication. Tier 2 drugs have a higher cost share than Tier 1. Thank you for your response. If you are charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. Sometimes, we must remove a drug immediately for safety reasons or due to its discontinuation by the manufacturer. Please help us improve MI by filling out this short survey. escitalopram Lexapro Oral tablets, oral solution and all strengths of Lexapro would be included in this listing. The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. There are several formulary options, so it depends on your patient’s plan which drugs are covered. In TX, services provided by Ingenio, Inc. A tiering exception request is a way to request lower cost-sharing. ... Ingenio will mail a letter to each participant whose drug is not on the new formulary. You may be able to file your request over the phone, but the plan can still require that your doctor submit a written statement of support. CoverMyMeds is the fastest and easiest way to review, complete and track PA requests. 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