DOWNLOADS | QUANTITY LIMIT MEDICAL NECESSITY - PROTON PUMP INHIBITORS FORM

This form should be used to request specific quantities of a class of drug known as Proton Pump Inhibitors, defined by the U.S. Food and Drug Administration as drugs that are used to "treat certain gastrointestinal disorders and work by reducing the amount of acid in the stomach." This form specifies quantity limits for a drug that can only be dispensed with an approved Prior Authorization.


Download the form (PDF).

Instructions

Filling out all fields in the form is is REQUIRED in consideration of approval for the prescribed quantity. Incomplete forms will be returned for additional information. Please fax the completed form to:

EHIM
Attn: Clinical Department
248-204-5604

If you have any questions about how to complete the form please feel free to contact EHIM at 800-311-3446.