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)