Form Phm 2 PDF Details

Pharmacists are an important part of the healthcare team, and their knowledge and expertise are relied on by patients and healthcare providers alike. In order to ensure that pharmacists can provide the highest quality care, it is important that they have up-to-date information about new medications and treatments. The Formulary Pharmacotherapy Management (Form Phm 2) course is designed to provide pharmacists with this information. The course covers a variety of topics, including new drugs and drug interactions, updated management recommendations for common diseases, and updates on the use of technology in pharmacy practice. pharmacists who take this course will be better equipped to provide safe and effective care for their patients.

QuestionAnswer
Form NameForm Phm 2
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesma 90 day waiver form, 90 day waiver form, mass health 90 day waiver form pharmacy, massachusetts 90 day waiver

Form Preview Example

Commonwealth of Massachusetts

Executive Office of Health and Human Services

www.mass.gov/masshealth

Pharmacy 90-Day Waiver Form

Use this form to request a 90-day waiver for one of the reasons indicated in the

Explanation box below. All fields must be completed to process the request.

Pharmacy information

 

 

 

 

 

 

 

 

 

 

(Required to receive approval notification)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

Pharmacy name

 

 

 

 

 

 

Provider number

Fax number

 

 

 

 

Location code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth member information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name

 

 

 

 

 

 

 

First name

 

 

 

Date of birth (mmddyyyy)

 

Gender

 

Member ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f

m

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturer

 

Item

 

 

Pkg.

 

Drug name

 

 

 

Quantity

 

Days’ supply

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber’s NPI

 

Date written

 

Date filled

 

Prescription no.

 

Usual charge

 

Other pd. amount

 

Prior auth. no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturer

 

Item

 

 

Pkg.

 

Drug name

 

 

 

Quantity

 

Days’ supply

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber’s NPI

 

Date written

 

Date filled

 

Prescription no.

 

Usual charge

 

Other pd. amount

 

Prior auth. no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturer

 

Item

 

 

Pkg.

 

Drug name

 

 

 

Quantity

 

Days’ supply

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber’s NPI

 

Date written

 

Date filled

 

Prescription no.

 

Usual charge

 

Other pd. amount

 

Prior auth. no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Manufacturer

 

Item

 

 

Pkg.

 

Drug name

 

 

 

Quantity

 

Days’ supply

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescriber’s NPI

 

Date written

 

Date filled

 

Prescription no.

 

Usual charge

 

Other pd. amount

 

Prior auth. no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explanation: Please indicate the reason for the 90-day waiver below.

Rebilling a previously denied timely filed claim (attach remittance advice)

Retroactive member enrollment (attach proof)

Retroactive provider enrollment (attach proof)

Please fax the completed form to Xerox State Healthcare at 1-866-556-9315.

Note: Submit claims that are older than 12 months (18 months for third party liability claims) directly to: MassHealth

Final Deadline Appeals, 100 Hancock Street, Quincy, MA 02171 (Tel.: 617-847-3115).

PHM-2 (Rev. 04/13)