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Quantity Limit Medical Necessity PPI

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This form should be used to request specific quantities of a class of drug known as Proton Pump Inhibitors (PPI). The U.S. Food and Drug Administration define a PPI as a drug that is used to "treat certain gastrointestinal disorders and works 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.

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

Attn: Clinical Department

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