Pharmacy Templates for Managed Care Organizations

Lock-In Templates

• Approval of PCP and Rx (Updated May 2020)
  
• Approval of PCP and Rx Denial (Updated May 2020)
  
• Approval of Rx and PCP Denial (Updated May 2020)
  
• Approval of Rx Only (Updated May 2020)
  
• Assignment of PCP and Rx (Updated May 2020)
  
• Denial of PCP and Rx (Updated May 2020)
  
• Denial of Rx Only (Updated May 2020)
  
• Notification of PCP and Rx (Updated May 2020)
  
• Notification of Rx Only (Updated May 2020)
  
• Notification of Rx Only add PCP (Updated May 2020)
  
• Provider Universal Approval-Denial (Updated May 2020)
  
• Removal from Program PCP and Rx (Updated May 2020)
  
• Removal from Program Rx Only (Updated May 2020)
  
• Request for Call Back PCP and Rx (Updated May 2020)
  
• Request for Call Back Rx Only (Updated May 2020) 

Other Pharmacy Related Member Communication Templates

• Member 60 Day Negative Change Notice (Updated May 2020)
• Negative PDL Change Notice (Updated October 2020)