Medco Health Form PDF Details

Have you ever had to fill out the Medco Health form? It can be a bit daunting, especially if you're not sure what all the questions are asking. In this blog post, we'll break down each section of the Medco Health form so that you know what to expect. We'll also explain why Medco asks for certain information.

This article holds information regarding medco health form. It'll provide you with the assumed time you'll need to fill out the form as well as further details.

QuestionAnswer
Form NameMedco Health Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedco health medicare part d prior auth, medco prior authorization, medco medicare part d prime prior authorization form, medco prior auth

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

© 2010 Medco Health Solutions, Inc. All rihts reserve.

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

1.

Yes

No

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*

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

© 2010 Medco Health Solutions, Inc. All rihts reserve.

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