2009 Medica Part D Prior Authorization Descriptions

Pharmacy / Pharmacist Information

Outcomes Pharmaceutical Health Care® MTM Services: For pharmacists interested in providing Medication Therapy Management (MTM) services to Medica members enrolled in certain Medicare Part D plans.



Medication Request Forms

• MN Uniform Formulary Exception Form
• General Medication Request Form - Medicare Part D
• Growth Hormone
• Xolair
• Epogen/Procrit/Aranesp
• Sporanox/Penlac

• General Patient Referral Form
• Amevive
• Enbrel
• First Dose Treatment Orders
• Fuzeon Therapy
• Growth Hormone
• Hepatitis C
• Infertility
• Multiple Sclerosis
• Oncology Self Injectables
• Oral Oncology
• Psoriasis
• Rheumatoid Arthritis
• Serostim

• Apokyn Prescription and Enrollment Form
• Apokyn Patient Consent and Agreement (PCA) Form
• Increlex Request Form
• Somavert Request Form
• Tracleer Request Form
• Xolair Prescription and Enrollment Form
• Xolair Patient Consent and Agreement (PCA) Form