Request Form For Medicare Prescription Drug Coverage Determination

2017 Request for Medicare prescription drug coverage determination

Page 1 of 2

(You must complete both pages.)

Please fax completed form to: 1-800-408-2386

For urgent requests, please call: 1-800-414-2386

Patient information

Prescriber information

Patient name

Today’s date

Physician specialty

Patient insurance ID number

Physician name

NPI/DEA number

Patient address, city, state, ZIP

Physician address, city, state, ZIP

Patient home telephone number

M.D. office telephone number

Gender

Patient date of birth

M.D. office fax number

Male

Female

Diagnosis and medical information

Medication requested

Strength and route of administration

Frequency

New prescription OR date therapy initiated

Quantity

Day supply

Expected length of therapy

Diagnosis (Please include all office notes supporting diagnosis.)

Please check all boxes that apply:

1. Check the box that best describes medication administration location:

Patient’s home or assisted living facilities

Office administered (pharmacy supplies drug)

Long Term Care Facilities(LTC)/Skilled Nursing Facilities (SNF)

Office administered (office supplies drug) /J CODE:

Ambulatory Infusion Center (infusion center supplies drug)

Other (explain):

Ambulatory Infusion Center (retail/outpatient pharmacy supplies drug)

Patient is stable on current drug(s) and/or current quantity, and therapy change would likely result adverse clinical outcome.

All covered Part D drugs on any tier of the plan’s formulary would not be as effective for the enrollee as the requested formulary

drug and/or would likely have adverse effects for the enrollee.

4. The American Geriatric Society recommends avoiding high risk medications (HRM) in the elderly as a safety concern. To ensure

safe use of potentially high risk medications (HRM) in the elderly population, prescriber must acknowledge that medication

benefits outweigh potential risks in the elderly. Note: Members under 65 years of age are not subject to the prior authorization

requirements.

The requested medication is medically necessary and the clinical benefits outweigh the risks for this specific patient.

Yes

Does patient have a diagnosis of cancer?

Yes

Is the patient on dialysis?

7. Complete this section if the requested drug is an immunosuppressant being used to prevent transplant rejection:

What was the date of the patient’s transplant (mm/dd/yy)?

8. Complete this section if the requested drug is being used in a nebulizer (inhalation solutions i.e albuterol, ipratropium, Tobi etc.)

or an infusion pump (insulin vials, morphine infusion, chemotherapy for liver cancer etc.):

The patient resides in one of the following long-term care (LTC) facilities:

•

A nursing home that is dually-certified as both a Medicare SNF and a Medicaid nursing facility (NF)

•

A Medicaid-only NF that primarily furnishes skilled care, a non-participating nursing home (i.e. neither Medicare nor Medicaid) that

provides primarily skilled care, an institution which has a distinct part SNF and which also primarily furnishes skilled care OR

The patient resides in his or her own home OR

The patient resides in an assisted living facility OR

The patient resides at other locations not listed here, provide the name, phone number and address :

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Insurance Portability and Accountability Act (HIPAA). The message is intended for the sole use of the individual or entity to whom it is addressed. If you are not the intended recipient,

you are notified that any use, distribution or copying of the attached material is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in

error, please notify us immediately by telephone at 1-800-414-2386.

GR-69170-1 (11-16) 2017