Adherence Packaging Request Form
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1Phone: (877) 644-4623
Fax: (888) 453-4756
Adherence Packaging Request
I. MEMBER INFORMATION
II. PHARMACY INFORMATION
Patient Name:
Pharmacy Name:
ID Number:
NPI:
Date of Birth:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone:
Primary Phone:
Fax:
Pharmacy Contact:
III. Adherence Packaging Checklist
Please complete the following reasons for adherence packaging.
Member has one of the following diagnosis:
HIV
Seizures
Visual Impairment
Severe and Persistent Mental Illness:
Schizophrenia
Bipolar Disorder
Major Depressive Disorder (MDD): ICD-10 F32 or F33
Cognitive Disorder:
Alzheimer’s
Traumatic Brain Injury (TBI)
Dementia
Intellectual or Developmental Disorder (IDD)
Member is receiving anti-rejection therapy for organ transplant
Member resides in a residential program (Group Home, Assisted Living Facility, Nursing Home, ICF/MR, PRTF)
Member is enrolled in the Lock-In Program
Member is enrolled in Pain Management Program/Pain Contract where adherence packaging is required
Adherence packaging is preventing a need for Home Health Services
Prescriber requires member to receive adherence packaging (Prescriber Name: _____________Phone: ___________)
Pharmacist-determined Medical Necessity for adherence packaging (please state reason below):
Reason:_________________________________________________________________________________
_________________________________________________________________________________
By signing below, I hereby acknowledge that all information is true and correct.
Pharmacist’s Name: _____________________ Pharmacist’s Signature: __________________ Date____/_____/____
Your attestation may be audited to request proof of the exception reason. Dispensing fees paid in excess of 90-day supplies may be recouped if
appropriate proof of member meeting criteria is not provided upon request.
IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under
applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to
disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.
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