Medco Health Form – Fill Out and Use This PDF

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

Form Preview Example

35045	35045
	Medicare Part D Prior Authorization Request Form (page 1 of 2)

Please complete both pages and return to Medco by fax at 1-800-837-0959.
Please indicate if you are requesting urgent processing		Yes

If yes, state rationale for urgent processing: _____________________________________________________

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

PATIENT INFORMATION

First and Last Name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Date of Birth: |__|__|/|__|__|/|__|__|__|__| Telephone: |__|__|__|-|__|__|__|-|__|__|__|__|

Medco Member ID Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| State:|__|__| Zip:|__|__|__|__|__| MEDICATION (that requires a coverage review)

Drug Name and Strength: _________________________________________________ Qty: _______________

Directions (SIG.):___________________________________________________________________________

Diagnosis: ________________________________________________________________________________

PRESCRIBER INFORMATION

First and Last Name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| State:|__|__| Zip:|__|__|__|__|__|

SECURE Fax: |__|__|__| - |__|__|__| - |__|__|__|__| Telephone: |__|__|__| - |__|__|__| - |__|__|__|__|

SECTION A: PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS

1.	Yes	No	Has your patient experienced INTOLERANCE or is INTOLERANCE SUSPECTED
			with any of the preferred alternatives?
2.	Yes	No	Has your patient experienced THERAPEUTIC FAILURE with any of the preferred
			alternatives or would failure be suspected with any of the preferred alternatives?
3.	Yes	No	Is this patient UNABLE TO USE the preferred alternative(s) because of DOSAGE
			FORM?
4.	Yes	No	Are there any preferred alternative(s) that can be used to treat this patient or patient's
			condition?
5.	Yes	No	Is a greater drug quantity necessary to achieve the prescribed dose?
6.	Yes	No	Is a greater quantity of medication needed to accommodate the frequency of use?

Location:NevadaCallCenter(15) CaseId:9999999

*9999999* *15* *35045*

Confidentiality Notice: This communication and any attachments are intended solely for the use of the addressee named above and contain confidential and legally privileged information. If you are not the intended recipient, any dissemination, distribution or copying is strictly prohibited. If you receive this communication in error, please notify Medco by fax or phone immediately. Medco facsimile machines are secure and in compliance with HIPAA privacy standards. THE PROVISION OF THE INFORMATION REQUESTED IN THIS FORM IS FOR YOUR PATIENT'S BENEFIT. MEDCO DOES NOT COMPENSATE FOR COMPLETING THIS FORM.

MED D_PA_W_V1

Y0046_MED D_PA_W_V1 CMS Approved 09132010

35045 *35045*

Medicare Part D Prior Authorization Request Form (page 2 of 2)

PLEASE RE-ENTER THE FOLLOWING INFORMATION ONTO THIS PAGE PATIENT INFORMATION

First and Last Name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Medco Member ID Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

MEDICATION (that requires a coverage review)

Drug Name and Strength: ____________________________________________________________________

Diagnosis: _______________________________________________________________________________

SECTION B: PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS

1.		Yes	No	Is the prescriber a Medicare-participating prescriber?
2.		Yes	No	Unknown	Is this patient currently enrolled in Part B coverage?

3.		Yes	No	Unknown/	Has coverage been denied under the Part B benefit?
				pending
4.		Yes	No	If YES to question 3, has Part B coverage of this medication been denied because of
				determination of lack of medical necessity?
5.		Yes	No	If YES to question 3, has Part B coverage of this medication been denied because of
				member ineligibility?
SECTIONC:COMPLETEIFAPPLICABLE:PATIENTSUSINGIMMUNOSUPPRESSANTMEDICATIONS

1.		Yes	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	No	Did the transplant occur at a Medicare-approved facility?
	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.
3.		Yes	No	Was the patient enrolled in Medicare Part A at the time of the transplant?

SECTIOND:COMPLETEIFAPPLICABLE:PATIENTSUSINGCHEMOTHERAPYAGENTS

Yes

Is the patient currently receiving or has the patient previously received the prescribed chemotherapy agent?

SECTIONE:IFAPPLICABLE,PLEASEPROVIDEADDITIONALRATIONALEBELOW

Prescriber's Signature: ________________________________________________________

FAX COMPLETED FORM TO 1-800-837-0959. (Please do not send with a cover sheet.)

Location:NevadaCallCenter(15) CaseId:9999999

*9999999* *15* *35045*

MED D_PA_W_V1

Y0046_MED D_PA_W_V1 CMS Approved 09132010

How to Edit Medco Health Form Online for Free

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medco medicare part d prime prior authorization form empty fields to consider

Enter the appropriate information in the segment SECTION A PLEASE ANSWER ALL OF THE, No Has your patient experienced, Yes, cid, cid, with any of the preferred, cid, Yes, cid, No Has your patient experienced, cid, Yes, cid, alternatives or would failure be, and cid.

step 2 to completing medco medicare part d prime prior authorization form

Describe the most significant details of the PLEASE REENTER THE FOLLOWING, Drug Name and Strength Diagnosis, Is the prescriber a, Is this patient currently enrolled, Yes Yes Yes, No No No, cid, cid, cid, cid, cid, cid, cid, Unknown Unknown pending, and cid area.

Entering details in medco medicare part d prime prior authorization form stage 3

The field Is the patient currently receiving, Yes, cid, cid, Prescribers Signature FAX, Location NevadaCallCenter CaseId, Confidentiality Notice This, and YMED DPAWV CMS Approved is where you can indicate all parties' rights and responsibilities.

medco medicare part d prime prior authorization form Is the patient currently receiving, Yes, cid, cid, Prescribers Signature FAX, Location NevadaCallCenter CaseId, Confidentiality Notice This, and YMED DPAWV CMS Approved fields to complete

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