Coverage Review Fax Form - HIE Networks

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Coverage Review Fax Form - HIE Networks

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expect the questionnaire faxed to you within 24 hours of your request. If the request is ... Location: Tampa Call Center

Coverage Review Request Form

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35045

To initiate a coverage review for your patient, please fax us this completed form. Please note that the completion of this form does not constitute completion of the coverage review process and is not a guarantee of benefit coverage. Upon receipt of this completed form, Medco will fax you the appropriate questionnaire. If your request is faxed 8:00 a.m. to 9:00 p.m., eastern time, Monday through Friday, you can expect the questionnaire faxed to you within 24 hours of your request. If the request is received outside of these time frames, the questionnaire will be faxed to you the next business day. Once the completed questionnaire is returned to Medco, a coverage decision will be faxed to you within 1 business day.

If your request is urgent or if you have questions, contact us toll-free at 1 800 753-2851. PATIENT INFORMATION

Last name: First name: Date of birth:

/

/

Telephone:

-

-

Medco member ID number: Address: City:

State:

Zip:

MEDICATION (that requires a coverage review)

Medication name: Strength:

& Qty.:

Directions (SIG.): PRESCRIBER INFORMATION

Last name: First name: Office address: City:

State:

SECURE fax :

Zip:

Telephone:

Signature:

Date:

FAX COMPLETED FORM TO 1 800 837-0959. (Please do not send with a cover sheet.) Location: Tampa Call Center (29)

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Case Id: 9999999

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Confidentiality Notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for the return of this document.

Medco facsimile machines are secure and in compliance with HIPAA privacy standards.

Form 001-W © 2006 Medco Health Solutions, Inc. All rights reserved.