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.
Question | Answer |
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Form Name | Form Phm 2 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | ma 90 day waiver form, 90 day waiver form, mass health 90 day waiver form pharmacy, massachusetts 90 day waiver |
Commonwealth of Massachusetts
Executive Office of Health and Human Services
www.mass.gov/masshealth
Pharmacy
Use this form to request a
Explanation box below. All fields must be completed to process the request.
Pharmacy information |
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(Required to receive approval notification) |
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Date |
Pharmacy name |
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Provider number |
Fax number |
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Location code |
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MassHealth member information |
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Last name |
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First name |
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Date of birth (mmddyyyy) |
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Gender |
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Member ID |
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Claim Information |
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Manufacturer |
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Pkg. |
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Drug name |
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Quantity |
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Days’ supply |
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1 |
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Prescriber’s NPI |
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Date written |
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Date filled |
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Prescription no. |
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Usual charge |
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Other pd. amount |
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Prior auth. no. |
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Prescriber’s NPI |
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Prescription no. |
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Usual charge |
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Other pd. amount |
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Prescriber’s NPI |
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Date written |
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Date filled |
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Prescription no. |
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Usual charge |
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Other pd. amount |
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Prior auth. no. |
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Manufacturer |
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Drug name |
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Prescriber’s NPI |
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Date written |
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Date filled |
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Prescription no. |
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Usual charge |
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Other pd. amount |
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Prior auth. no. |
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Explanation: Please indicate the reason for the
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
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.: