Get Medicare Der Form.doc - Mainecarepdl

The Medicare Drug Evaluation Review Form is essential for obtaining coverage for non-formulary medications. Completing this form accurately ensures that patients receive the necessary medications based on medical needs and established guidelines.

Follow the steps to complete the Medicare DER Form online:

1. Press the ‘Get Form’ button to obtain the Medicare DER Form and open it in your preferred online editor.
2. Begin filling out the form by providing the member’s name in the designated field, ensuring clarity and legibility.
3. Enter the date of request. This should reflect the exact date you are submitting the request.
4. Fill in the Health Plan ID# to identify the member’s plan accurately.
5. Specify the health plan as 'WellCare PDP' in the relevant section.
6. Indicate the state where the member resides.
7. Choose the relevant plan by marking the applicable option: Signature, Complete, or Premier.
8. Provide the member’s date of birth (DOB) to verify eligibility.
9. Enter the physician’s name responsible for the patient’s care.
10. Document the diagnosis relevant to the request for the non-formulary medication.
11. Include the specialty of the physician for accurate categorization.
12. List the drug name for which the override is being requested.
13. Specify who is sending the request in the 'Sent By' section.
14. Enter the prescribed dose and the dosage form for the medication.
15. Provide the strength and quantity (Qty) of the medication needed.
16. Include the physician’s phone and fax numbers for follow-up communication.
17. Specify the length of treatment required for the prescribed medication.
18. List the pharmacy phone number where the prescription will be filled.
19. Clearly articulate the clinical reason for requesting an override, including any necessary medical documentation.
20. Detail previous medications that have failed, including the names, doses, and strengths.
21. If you require additional space for history, include a separate sheet with the patient’s ID#, DOB, and name, along with pertinent medical records.
22. Review all entered information for accuracy and completeness before submission.
23. Once completed, save changes to the form and choose to download, print, or share as necessary.

Complete the Medicare DER Form online to ensure timely access to essential medications.