Pharmacy Referral Form - ww3iehporg 2026

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The document is a pharmacy referral form for the administration of 17-alpha hydroxyprogesterone caproate (17P) for patients with singleton pregnancies at risk of preterm delivery. It includes sections for patient and prescriber information, prescription details, and instructions for medication delivery. The form emphasizes confidentiality and compliance with HIPAA standards.

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Click ‘Get Form’ to open the Pharmacy Referral Form in the editor.
Begin by entering today's date at the top of the form. This is essential for tracking purposes.
Fill in the patient’s contact telephone number, name, date of birth, and home address including city, state, and ZIP code. Ensure all information is accurate.
Provide the Medicaid ID and HCP Group ID along with the HCP ID for proper identification.
Indicate the primary diagnosis and corresponding ICD-10 code. This helps in understanding the medical necessity for treatment.
Complete the prescription information section by specifying the medication details, dosage, and administration instructions as outlined in the form.
Fill out prescriber information including their name, phone number, office name, address, NPI, DEA number, and state medical license number.
Finally, ensure that you sign where indicated. Remember that signature stamps are not accepted.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Who is the PBM for IEHP?

MedImpact maintains the Pharmacy Benefit drug pricing for IEHP DualChoice and IEHP Covered California. Medimpact also addresses pharmacy provider appeals on drug pricing.

How long do IEHP referrals take?

This is how referrals work: When the request is received by IEHP, a decision will be made within 5 business days for a regular referral. For an urgent referral, this is done within 72 business hours. For a regular referral, expect a letter from your medical group or IEHP within 2 days after a decision has been made.

What is the referral process?

A referral is a letter from your doctor to another health professional or health service. Most referrals are from GPs to specialists and last for 12 months. If you have a referral, Medicare should cover part of the costs for further tests or treatment.

What is the referral policy for Iehp?

UPON ACCEPTANCE OF REFERRAL AND TREATMENT OF THE MEMBER, THE PHYSICIAN/PROVIDER AGREES TO ACCEPT IEHP CONTRACTED RATES. This referral/authorization verifies medical necessity only. Payments for services are dependent upon the Members eligibility at the time services are rendered.

What is the phone number for Iehp authorization?

Medical Reviewer Signature (Circle Title: MD, DO, RN, LVN, Coordinator) Date Criteria utilized in making this decision is available upon request by calling IEHP (866) 725-4347.