Welcome to the Prescriber Portal. We’re dedicated to bringing you the information you need to best care for your patients.
Here you can quickly access coverage determination links, forms, and other helpful information.
The EnvisionRx Pharmacy and Therapeutics (P & T) Committee is a multidisciplinary team of physicians, pharmacists, and other health care professionals that provides clinical oversight of the drug utilization management process. This information is available to prescribers upon request.
For any questions, please contact us.
Coverage Determination Links
Coverage Determination Forms – Search By Drug
Coverage Determination Forms
- CFI Non Formulary Exception Form 472
- EIC Non Formulary Exception (NFE) Request Medicare 3823
- EnvisionRx Age Limit Override 3998
- EnvisionRx DAW Penalty Form 5322
- EnvisionRx General Prior Authorization- 1 6534
- EnvisionRx General Step Therapy Exception Form 3995
- EnvisionRx Quantity Limit Exception (QLE) 3996
- EnvisionRxOptions On-Line Prior Authorization Form 12215
- Market Priced Drug Program Exception Request Form
- NWI Non Formulary Exception 480
- Quantity Limit Exception (QLE)-1 Medicare 3825
- Tier Exception (TE)-1 Medicare - 3826
State of Maryland Forms