Avmed Request Form PDF Details

If you are a current or former employee of Avmed, you may be wondering about how to access your benefits information. This guide will explain the process of requesting your benefits information from Avmed. First, you will need to complete the Avmed Request Form and submit it to the company. You can either fax or mail the form to Avmed, depending on which method is most convenient for you. Once the form has been processed, you will receive a Benefits Summary Report that outlines all of the benefits you are eligible for. If you have any questions about your benefits, be sure to contact the Avmed Benefits team for more help.

QuestionAnswer
Form NameAvmed Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesINR, avmed report form, medco, pa

Form Preview Example

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

Member ID

 

Date of Birth

 

Is Member Pregnant? Yes

No

 

 

 

 

 

 

 

Member Name

 

Height

Weight

 

 

 

 

 

 

 

 

Diagnosis

 

Diagnosis (ICD-9) Code

 

 

 

 

 

 

 

 

 

 

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

contact 352-337-8774 to request an enrollment form or if you have

 

 

 

 

any questions.

 

 

 

 

If being administered in an out-patient facility setting:

Please choose below:

 

Accredo – patient delivery (self inject)

 

 

 

 

Name of Facility: ___________________________

Accredo– MD office delivery

 

 

 

 

 

Facility Provider Number: _________________________

Accredo can be reached at:

 

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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