Request for Prescription Information or Change Form

Request for Medicare Part D Prescription Information or Change FormThis form should only be used for BlueMedicare Rx for Medicare Part D and Medicare Advantage(BlueMedicare PPO and BlueMedicare HMO) requests for prescription information or change.To: (Prescribing Physician): ______________________________ Date: __________________________Fax: ___________________________________Phone: ____________________________________Patient Name: ________________________________________________________________________Name of Drug Plan: ________________________ Plan Phone (if available): ______________________Member Number: _________________________ Prescription Number: _________________________Prescription IssuesThe patient’s drug plan has indicated that it will not pay for __________________________________________________________________ for this patient because:Prior authorization requiredStep therapy required. Plan will pay for: __________________________________________Plan only authorizes __________________ dosage units (tablets/capsules) per prescriptionPlan does not pay for drug in dosage/format prescribedDrug is not on the formulary Note:Plan authorized one-time only payment for this drugPlan did not authorize one-time paymentOther drugs on the formulary include (if available): ___________________________________________________________________________________________________Other reason(s): _______________________________________________________The patient’s drug plan covers this drug, but with a higher tiered copay. Preferred drugsavailable at lower copay (if available): ___________________________________________.Action Requested – Please Respond to Pharmacy:Pharmacist Requesting Action (Name): _________________________________________________Urgent – patient is waitingBy next refill: __________________________ Date: _________________________________900-444-0107 January 2007

Provide alternative medication: __________________________________________________Other recommended action: ____________________________________________________Physician Signature: ________________________________ Date: _____________________________Action Requested – Contact Drug Plan to Request: prior authorization formulary exceptionInformation Only – No Immediate Action NecessaryPlease Note: Medicare Part D does not pay for barbiturates, benzodiazepines, fertility drugs, drugs for weight loss orweight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins andfluoride preparations).From: Pharmacy Name: ________________________________________________________________Fax: ______________________ Phone: ______________________ Email: ______________________Address: ____________________________________________________________________________Information on this form is protected health information and subject to all privacy and security regulations underHIPAA. Use of this form is endorsed by the Alzheimer’s Association, American Medical Association, AmericanPharmacists Association, Center for Medicare Advocacy, Medical Group management Association, NationalCommunity Pharmacists Association and the National Council on the Aging.The Centers for Medicare & Medicaid Services has reviewed this fax form, but does not require its use. Use of theform for communications between pharmacists and physicians is voluntary. It is not a legal document. The officialMedicare program provisions are contained in relevant laws, regulations, and rulings.900-444-0107 January 2007