SDS 728

SDS 728
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MMA Problem Solving Referral Form
***Please email to [email protected]***
Aging and People with Disabilities
Referral date:
Referral from:
Pharmacy
Urgent case?
Client’s name:
Yes
Client’s prime:
Date of birth:
Dual status confirmed?
Local office
No
Family member
Facility
Care provider
Day client was or will be out of medication:
Client’s phone:
Client’s Medicare number:
No
Yes
Case worker:
Family member or other contact:
Phone:
Branch:
Pharmacy:
Pharmacy phone:
Pharmacy fax:
or QMB/SLMB only
Full
Phone:
Drug(s) not covered:
First plan:
Effective dates:
Second plan:
Effective dates:
from
to
Prescribing physician:
from
to
Physician’s phone:
Description of problem
No part D plan
Pharmacy unable to bill plan
Client told they are still in previous
Client being billed premium
plan/wrong plan being billed
Drugs not on formulary
Client being charged deductible/
Prior authorization problems
wrong co-payment-LIS not correct
Quantity limit problems
Client paid incorrect amount
No transition benefit provided
Prescription Co-pay Coverage (PCC)
Has a drug coverage exception been filed?
Yes
No Status:
Please provide copies of any requests, denials or decisions made.
Other notes:
SDS 0728 (08/14)
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