STAR + PLUS Coverage Determination Request Form

Member Information

Customer ID:	*
Patient First Name:	*
Patient Last Name:	*
Patient Date of Birth:	*
Patient Phone:	*
Patient Address:	*

Physician Information

Physician NPI:	*
Physician First Name:	*
Physician Last Name:	*
Physician Specialty:	*
Contact Name:	*
Physician Phone:	*
Physician Fax:	*
Physician Address:	*

Medication Information

Medication Name:	*
Dosage:	*
Quantity:	*
Frequency:	*

Diagnosis Information

Prescibing Diagnosis:	*
Diagnosis Code(s):	*
Date Therapy Initiated:	*

Clinical Criteria

Please provide rationale supporting your request for Coverage Determination. If request is for a non-preferred medication, please provide clinical documentation supporting: Name of preferred therapy, dates and duration of alternate therapy tried and response to therapy.
Clinical Criteria:	*
*Failure to provide clinical documentation supporting rationale may result in this request being denied.* Note: Scanned or other electronic documents cannot be uploaded or attached. If you have additional supporting documents, you will need to mail or fax them separately to the number or address below.

Additional Info

Prescribers and pharmacists may access the Cigna-HealthSpring/Texas Medicaid formulary and PDL through the Texas Vendor Drug Program’s website: www.txvendordrug.com. The Vendor Drug Program’s website includes instructions for how to register with Epocrates, providing free access to the formulary and PDL on handheld devices.

Drugs with quantity limits may be viewed at: http://starplus.cignahealthspring.com/GetFile.Ashx?fileid=4367
Drugs with clinical edits may be viewed at: http://starplus.cignahealthspring.com/clinicaledits