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.
| 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 health medicare part d prior auth, medco prior authorization, medco medicare part d prime prior authorization form, medco prior auth |
35045 |
*35045* |
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Medicare Part D Prior Authorization Request Form (page 1 of 2) |
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Please complete both pages and return to Medco by fax at |
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Please indicate if you are requesting urgent processing |
Yes |
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If yes, state rationale for urgent processing: _____________________________________________________
If you have any questions, you may contact us
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 |
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with any of the preferred alternatives? |
2. |
Yes |
No |
Has your patient experienced THERAPEUTIC FAILURE with any of the preferred |
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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 |
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FORM? |
4. |
Yes |
No |
Are there any preferred alternative(s) that can be used to treat this patient or patient's |
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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
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. |
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Yes |
No |
Is the prescriber a |
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2. |
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Yes |
No |
Unknown |
Is this patient currently enrolled in Part B coverage? |
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3. |
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Yes |
No |
Unknown/ |
Has coverage been denied under the Part B benefit? |
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pending |
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4. |
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Yes |
No |
If YES to question 3, has Part B coverage of this medication been denied because of |
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determination of lack of medical necessity? |
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5. |
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Yes |
No |
If YES to question 3, has Part B coverage of this medication been denied because of |
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member ineligibility? |
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SECTIONC:COMPLETEIFAPPLICABLE:PATIENTSUSINGIMMUNOSUPPRESSANTMEDICATIONS |
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1. |
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Yes |
No |
Is the immunosuppressant medication being used subsequent to a transplant? |
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If |
you answered YES to question 1, please proceed to questions 2 and 3. |
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2. |
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Yes |
No |
Did the transplant occur at a |
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In accordance with CMS Immunosuppressive Drugs Policy Article (A25366), effective July 2008 |
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Medicare Part B will cover immunosuppressant agents when used for a transplant if the beneficiary was |
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enrolled in Part A at the time of the transplant and the transplant occurred at a |
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whether or not Medicare Part A made payments for the transplant. |
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3. |
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Yes |
No |
Was the patient enrolled in Medicare Part A at the time of the transplant? |
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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
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.