Get 2011 Medicare Part D Step Therapy Physician Fax Form

Filling out the 2011 Medicare Part D step therapy physician fax form can seem challenging, but this guide provides clear instructions to help prescribers complete the form accurately online. Ensuring that all required information is filled out will facilitate a smoother submission process.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient's information in the designated fields. This includes the patient's first and last name, insurance ID number, date of birth, and telephone number.
3. Provide the prescribing physician's information, including their name, NPI number, specialty, and the clinic's contact details such as name, address, and phone number.
4. Indicate whether the patient is a resident of a long-term care facility. If yes, include the facility contact's name, along with their phone and secure fax numbers.
5. Complete the patient's weight and diagnosis, including the ICD-9 code and a brief description.
6. Detail the medication requested, including its strength, dosing schedule, and the quantity needed per month.
7. Answer questions regarding the patient's current treatment with the requested medication, including when treatment started and if a lower dose is currently being used.
8. List all reasons for selecting the requested medication over alternatives, including any contraindications, allergies, or adverse reactions.
9. Provide a list of all medications the patient has previously tried and failed for the diagnosis, being specific about brand-name and generic products.
10. Mention any other medications the patient will use in conjunction with the requested medication for treatment.
11. Ensure all information is accurate and complete, then save your changes, download, print, or share the form as needed.

Complete your documents online to ensure efficient processing of Medicare Part D requests.