Avmed Request Form – Fill Out and Use This PDF

Avmed Request Form PDF Details

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Avmed Request Form – Fill Out and Use This PDF

The AvMed Request Form is a critical document for patients and healthcare professionals looking to request specific medications not typically covered under standard pharmacy benefits or those requiring special approval due to their nature, like medically administered drugs. Essentially, it serves as a pathway to request an exception for commercial medication, outlining the need for drugs administered by health professionals or for self-administration under the pharmacy benefits. Whether the need is routine or urgent, this form facilitates the appropriate submission of medication requests to AvMed. Need to make a medication request? Simply click the button below to get started with the AvMed Request Form.

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Avmed Request Form PDF Details

Navigating the healthcare landscape can be complex, especially when it comes to accessing necessary medications. The Avmed Request form plays a crucial role in this process, particularly for medications that are not directly covered under a patient's standard pharmacy benefit. Specifically designed for both commercially available medications and those requiring an exception due to their nature (such as medications administered by a health professional), the form encompasses a wide array of drugs, from Abraxane to Xolair. It distinguishes between routine requests, processed within 14 days, and urgent ones, reviewed in just 3 days, ensuring patients receive the necessary medications promptly. It also requires detailed patient information, including member ID and diagnosis codes, and outlines specific directions for medication delivery and administration, whether in a doctor's office or through a specialty pharmacy program. By mandating comprehensive details like the physician's name, specialty, and contact information, along with a requirement for attaching office notes and current lab results, the form ensures a thorough review process. This meticulous approach helps in minimizing delays or denials due to incomplete information, facilitating a smoother pathway for patients in need of these critical medications.

Question	Answer
Form Name	Avmed Request Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	INR, avmed report form, medco, pa

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COMMERCIAL MEDICATION EXCEPTION REQUEST FORM 2014

Date of Submission: ______________________

Action Needed:

Routine (Reviewed within 14 days of all information being received)

Urgent (Reviewed within 3 days of all information being received)

Request for any medication below: (Medical Benefit Medications ie. Health professional administered)

+Abraxane+

+Actemra+

+Adcetris+

+Alimta+

+Aloxi+

+Aranesp+

+Avastin+

Benlysta

Botulinum toxin	+Gammagard+	+IVIG+	Neumega	Provenge	Tysabri

+Carimune NF+	+Gammagard SD+	+Jevtana+	+Neupogen+	+Remicade+	+Vectibix+

Cinryze	+Gammaplex+	Kadcyla	Nplate	Remodulin	Xiaflex
+Epogen+	+Gamunex+	Krystexxa	+Octagam+	+Rituxan+	Xolair
epoprostenol (Flolan)	Gel-One	+Leukine+	+Orencia IV+	Soliris	+Yervoy+
+Erbitux+	+Halaven+	Lupron Depot	+Perjeta+	+Stelara+
Erwinaze	+Herceptin+	Makena	+Privigen+	Supprelin LA
+Flegogama+	Intron-A	+Neulasta+	+Procrit+	Synagis

+Contact ICORE at 800-424-1740 or www.icorehealthcare.com for PA on MD office administered drugs indicated with a “+” only, OR complete and fax to AvMed at 877-535-1391 for all others

Request for all other medications: (Pharmacy benefit medications ie. Patient self administered)

Fax Prior Authorization to AvMed at 877-535-1391

PATIENT INFORMATION

DELIVERY – ADMINISTRATION INFORMATION

In-office (MD to supply and administer)		Accredo is AvMed’s exclusive specialty pharmacy. If you are
		requesting medication delivery to your office, enrollment in the
Retail pharmacy Pickup		Accredo Specialty Medication Delivery Program is required. Please
Retail pharmacy Pickup		contact 352-337-8774 to request an enrollment form or if you have

		any questions.
		any questions.
If being administered in an out-patient facility setting:		Please choose below:
If being administered in an out-patient facility setting:		Accredo – patient delivery (self inject)
		Accredo – patient delivery (self inject)
Name of Facility: ___________________________		Accredo– MD office delivery
Name of Facility: ___________________________
Facility Provider Number: _________________________		Accredo can be reached at:
Facility Provider Number: _________________________		phone: 877-634-8555
		phone: 877-634-8555
		fax: 888-773-7386

	ADDITIONAL MEDICATION INFORMATION

Drug Name			Quantity

Directions for Use			New Therapy	Continuation of Therapy

If Continuation of therapy, indicate the member’s therapeutic response:

Duration of Therapy

Reason for Request

Procedure Code

MUST ATTACH OFFICE NOTES AND CURRENT LAB RESULTS.

Incomplete forms and/or inadequate documentation may result in denial.

Physician Name

PHYSICIAN INFORMATION

Physician Specialty

NPI #

AvMed Provider #

Phone Number

Ext

Fax Number

Office Contact Name

Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended recipient, you hereby are advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please immediately notify the sender by telephone and destroy this original

fax message. MP-3160

Rev 121613

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Date of Birth

Is Member Pregnant? Yes

Member Name

Diagnosis (ICD-9) Code