Please attach all Office Notes and Current Lab Results Download

Transcript
MEDICARE MEDICATION EXCEPTION REQUEST FORM 2015
Date of Submission: ______________________
Actemra
Intron-A
Makena
+Procrit+
Synagis
+Adcetris+
+IVIG+
+Neulasta+
+Provenge+
+Synribo+
+Aranesp+
+Jevtana+
+Neumega+
Remicade
Tysabri
Benlysta
+Kadcyla+
+Neupogen+
+Rituxan (RA
only)
Voraxaze
Botulinum toxin
Krystexxa
+Nplate+
Signifor
Xiaflex
Complete and fax to AvMed to:
Cinryze
+Kyprolis+
Nulojix
+Soliris+
Xolair
1-305-671-0189
+Epogen+
+Leukine+
Orencia IV
Stelara
+Yervoy+
+Erwinaze+
Lupron Depot
+Perjeta+
Supprelin LA
+Zaltrap+
All Medications listed in the table
require a PA. Please include Office
Notes and Labs with all requests
Request for all other medications:
Cancer and Hemolytic (+) indications written by an oncologist or hematologist are reviewed through New Century Health.
(Please go to https://my.newcenturyhealth.com, FAX 1-877-624-8602, Phone 1-888-999-7713)
For all other specialties and physicians, a PA is required. Please fax Office notes and Labs to 305-671-0189 or 877-535-1391
PATIENT INFORMATION
Member ID
Date of Birth
Is Member Pregnant?
Member Name
Height
Weight
Diagnosis
Diagnosis
(ICD-9) Code
Yes
No
DELIVERY – ADMINISTRATION INFORMATION
In-office (MD to supply and administer)
If you are requesting medication delivery to your office, enrollment
in the Accredo Specialty Medication Delivery Program is required.
Retail pharmacy Pickup (Medicare Part D)
Home Health Provider
Outpatient Facility
Please choose below:
Accredo – Patient delivery (self-administered specialty meds)
Infusion Suite
Accredo – MD office delivery
Name of Facility/Suite: ___________________________
Facility/Suite Provider Number: _________________________
Accredo can be reached at :
Phone: 877-634-8555 Fax: 888-773-7386
ADDITIONAL MEDICATION INFORMATION
Please attach all Office Notes and Current Lab Results
Incomplete forms and/or inadequate documentation may result in a denial
Drug Name
Quantity
Directions for Use
New Therapy
Continuation of Therapy
If Continuation of Therapy, indicate the member’s therapeutic response:
Duration of Therapy
Procedure Code
Reason for Request
PHYSICIAN INFORMATION
Prescriber Name
Prescriber Specialty
Form Completed By
AvMed Provider #
NPI #
Office Number
Contact Name
Fax Number
Ext
Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended recipient, you hereby are advised that any
dissemination, distribution, or copying of this communication is prohibited. If you have received this fax in error, please immediately notify the sender by telephone and destroy this original fax message.
MP-3160
Rev082015