Please Return Page 2 via fax to (512) 738-8397

Attention: TEST Prescriber M.D.

From: Wilmington Health

Subject: Medication Conversion Authorization Order

What We Need From You

Please review our suggested changes against your patients medication profile and consider the switch.
Consider the patient's allergies, comorbidities, contraindications, specific indications being treated, and previous
therapies when determining if this switch is indicated for your patient.

1. Please complete Page 2 with your selection or reason for rejection and fax back to (512) 738-8397

2. If you use your EHR system to complete the authorization please check the "Approved through EHR Box" on
authorization and fax back as in step 1. This will eliminate additional follow up and fax duplication on this patient.

If you feel this conversion was done in error, either due to the patient or source medication, please contact Wilmington
Health Plan RX program at (888) 255-2033.

Who We Are

RazorRx Assistant is a prescription benefit program partnered with the Wilmington Health plan to recommend
member prescription equivalent medication like generics to save on drug costs for members by analyzing claims
data. We are designed and supported by physicians and pharmacists, saving members over $300 on average per
year!

How We Do It

We review the claims data provided by Wilmington Health, plan administrator analyzing their formulary, medication
classes, medications with similar indications and the individual’s fill history. After this thorough analysis, we present
the physician with less expensive alternatives.

We aim to make this as easy as possible for you and present the FDA approved indications for the target
medication and a field for you to customize the order.

Questions about the program please email questions to questions@razormetrics.com

Please Return Page 2 via fax to (512) 738-8397

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 Medical Conversion Authorization Order
REF 00000214-0001

Patient Patient 3867549 DOB 08-13-1969 Phone 1234567890

Address 3867549 Main street, Anywhere USA 12345

The following change(s) to the patient's medication therapy is requested on behalf of Wilmington Health.
Please review this change against the patient's record and update accordingly. Please consider this
change, as our review of the previous 12 months fill history shows a potential cost savings for the patient
and the employer.

DISCONTINUE NEXIUM (Last filled on 01-05-19 for 30 days)

START Use for next patient refill but NOT BEFORE 03-13-2019

Omeprazole (Prilosec Generic)

[ ] (10 mg) Take 1 capsule by mouth every day
[ ] (20 mg) Take 1 capsule by mouth every day
[ ] (20 mg) Take 1 capsule by mouth twice a day
[ ] (40 mg) Take 1 capsule by mouth every day
[ ] Strength: ____ sig: ______________________________________
Days Supply: [ ] 30 [ ] 60 [ ] 90 [ ] Other __________

Refills: [ ] 1 [ ]2 [ ]3 [ ] Other __________

[ ] Submitted via EHR => return fax to ensure patient notification

Patient is not a candidate for this switch due to ______________________

COMMENTS:

Prescriber Signature _________________________________ Date _________________

Prescriber: TEST Prescriber M.D. -- 1111111111

Pharmacy: TEST PHARM #111 -- 1111111111

Please Return this page via fax to (512) 738-8397

This facsimile transmittal is intented only for the use of the individual or entity to which it is addressed. It may contain information that is privileged,
confidential and exempt from disclosure under law. If the reader of this message is not the intended recipient, you are notified that any
dissemination, distribution or copying of this communication is strictly prohibited. If you are not the intended recipient, you are hereby notified that
law strictly prohibits any disclosure, copying, distribution or action taken in reliance on the contents of these documents. If you have received this
fax in error, please notify the sender immediatley to arrange for return of these documents

REF 00000214-0001

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