Medco Health Form – Fill Out and Use This PDF

Updated: Nov 9, 2026

The Medco Health Medicare Part D Prior Authorization Request Form is a crucial document for patients seeking coverage for specific medications under their Medicare Part D plan. It requires detailed information from both the patient and the prescriber, including medication details, patient's medical history, and the prescriber's contact information. To expedite the process, urgent processing can be requested with a valid rationale. Click the button below to ensure your form is filled out correctly and promptly.

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Medco Health Form PDF Details

As the healthcare landscape continues to evolve, ensuring that patients receive the necessary medication under Medicare Part D can pose challenges. The Medco Health Medicare Part D Prior Authorization Request Form serves as a critical tool in this process, facilitating communication between healthcare providers and insurance to secure coverage for prescribed medications. This comprehensive form, spanning two pages, requires detailed information about the patient, the medication requiring review, and extensive prescriber details. It also includes a section for indicating the urgency of the processing request, highlighting situations where time is of the essence for the patient's health. Additionally, the form incorporates a series of questions aimed at determining the necessity of the medication and its compliance with Medicare regulations, including specifics about drug intolerance, therapeutic failure, and dosage requirements. It extends to cover situations like the use of immunosuppressant medications post-transplant and chemotherapy agents, aligning with specific CMS policies. Importantly, this form underscores the importance of confidentiality and HIPAA compliance, reminding healthcare professionals of the secure nature of the communication. With no compensation provided for completing this form, it emphasizes that the primary motive is the patient's benefit, ensuring they receive the medication they need under their Medicare Part D benefits.

Question	Answer
Form Name	Medco Health Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	medco prior auth form, medco prior uathorization form, medco prior auth, medco prior authorization phone number

How to Fill Out Medicare Part D Prior Authorization Request Form

Medicare Part D Prior Authorization Request Form at a glance

What it is: Medicare Part D Prior Authorization Request Form, with a medication that requires a coverage review.

Where and when to file: Complete both pages and return to Medco by fax at 1-800-837-0959.

A filled-in Medicare Part D Prior Authorization Request Form example: urgent request with one intolerance

Medicare Part D Prior Authorization Request Form example filled out, example: urgent request with one intolerance — A prescriber fills out page 1 of the Medicare Part D form. The patient's request is urgent, so Yes is ticked and a rationale is entered. In SECTION A, question 1 is Yes and questions 2 to 6 are No. The prescriber signs page 2 by hand, so nothing goes in Prescriber's Signature. The picture shows page 1 only and all its values are invented.

How to fill out Medicare Part D Prior Authorization Request Form, box by box

Urgent processing

Indicate if you are requesting urgent processing. If yes, state rationale for urgent processing.

PATIENT INFORMATION and MEDICATION (that requires a coverage review)

Under PATIENT INFORMATION, enter First and Last Name, Date of Birth, Telephone, Medco Member ID Number, Street Address, City, State and Zip.

Under MEDICATION (that requires a coverage review), enter Drug Name and Strength, Qty, Directions (SIG.) and Diagnosis.

SECTION A: PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS

In SECTION A, answer all of the following questions. 1. Yes or No: Has your patient experienced INTOLERANCE or is INTOLERANCE SUSPECTED with any of the preferred alternatives?

SECTION A, 2. Yes or No: Has your patient experienced THERAPEUTIC FAILURE with any of the preferred alternatives or would failure be suspected with any of the preferred alternatives?

SECTION A, 3. Yes or No: Is this patient UNABLE TO USE the preferred alternative(s) because of DOSAGE FORM?

SECTION A, 4. Yes or No: Are there any preferred alternative(s) that can be used to treat this patient or patient's condition?

SECTION A, 5. Yes or No: Is a greater drug quantity necessary to achieve the prescribed dose?

SECTION A, 6. Yes or No: Is a greater quantity of medication needed to accommodate the frequency of use?

Re-entering the information on page 2

On page 2, re-enter PATIENT INFORMATION (First and Last Name, Medco Member ID Number) and MEDICATION (that requires a coverage review) (Drug Name and Strength, Diagnosis).

SECTION B: PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS

In SECTION B, answer all of the following questions. 1. Yes or No: Is the prescriber a Medicare-participating prescriber?

SECTION B, 2. Yes, No or Unknown: Is this patient currently enrolled in Part B coverage?

SECTION B, 3. Yes, No or Unknown/pending: Has coverage been denied under the Part B benefit?

SECTION B, 4. Yes or No: If YES to question 3, has Part B coverage of this medication been denied because of determination of lack of medical necessity?

SECTION B, 5. Yes or No: If YES to question 3, has Part B coverage of this medication been denied because of member ineligibility?

SECTION C: IMMUNOSUPPRESSANT MEDICATIONS

SECTION C: complete if applicable, patients using immunosuppressant medications. 1. Yes or No: Is the immunosuppressant medication being used subsequent to a transplant?

If you answered YES to question 1, please proceed to questions 2 and 3. 2. Yes or No: Did the transplant occur at a Medicare-approved facility?

SECTION C, 3. Yes or No: Was the patient enrolled in Medicare Part A at the time of the transplant?

In accordance with CMS Immunosuppressive Drugs Policy Article (A25366), effective July 2008 Medicare Part B will cover immunosuppressant agents when used for a transplant if the beneficiary was enrolled in Part A at the time of the transplant and the transplant occurred at a Medicare-approved facility, whether or not Medicare Part A made payments for the transplant.

SECTION D: CHEMOTHERAPY AGENTS

SECTION D: complete if applicable, patients using chemotherapy agents. 1. Yes or No: Is the patient currently receiving or has the patient previously received the prescribed chemotherapy agent?

SECTION E

In SECTION E, please provide additional rationale if applicable.

Prescriber's Signature

Under Prescriber's Signature, sign. Fax completed form to 1-800-837-0959. (Please do not send with a cover sheet.)

More rules for Medicare Part D Prior Authorization Request Form

Under PRESCRIBER INFORMATION, enter First and Last Name, Street Address, City, State, Zip, SECURE Fax and Telephone.

If you have any questions, you may contact Medco toll-free at 1-800-753-2851.

Sources

[1] Medicare Part D Prior Authorization Request Form (MED D_PA_W_V1), Medco (the served file; no issuer file found) (the Official source link on this page).