Resources for Pharmacy & Prescribers Medical Necessity Form Medical Necessity Patient Name * First Name Last Name Patient Date of Birth * MM DD YYYY Date of Injury MM DD YYYY Prescriber Name * First Name Last Name Prescriber NPI * Prescriber Email * Prescriber Phone Country (###) ### #### Please provide more information about the medication for which you are submitting a medical necessity request. Medication Name and Dose * Name and Dosage Has the patient previously tried the generic version of this medication? * Yes No Has the patient previously tried a therapeutic alternative to this medication? * Yes No Has the patient experienced a documented adverse reaction or therapeutic failure with the generic equivalent? Yes No Does the patient have a medical condition that interferes with absorption or metabolism of the generic formulation? * Yes No Is there a known allergy or hypersensitivity to a specific inactive ingredient (e.g., dye, preservative, binder) in the generic that is not present in the brand? * Yes No Has a treating specialist (e.g., neurologist, endocrinologist) recommended continued use of the brand based on clinical judgment or patient history? * Yes No Thank you for submitting! Pharmacy Network Application Payer Sheet Prior Authorization Form MAC Appeals Form Submit Mac Appeals Online MAC Appeals Online Submission MAC Appeal Name * First Name Last Name Email * Pharmacy Name * Pharmacy Phone Number * Pharmacy NPI * Rx Number * Date Filled * MM DD YYYY Number Chain Code * NDC Number * Quantity/Units * Acquisition Cost * $ Invoice Number * Thank you! File Complaint Provider Complaint Form Provider Complaint Form Name * First Name Last Name Email * Pharmacy Name * Pharmacy Phone Number * Pharmacy NPI * Rx Number * Complaint * Please state complaint with as much details as possible including dates, Rx number, member ID, etc. Thank you! Request Contract/Provider Manual Provider Contract Request Provider Contract Request Name * First Name Last Name Email * Pharmacy Name * Pharmacy NPI * Pharmacy NABP Number * Pharmacy Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pharmacy Phone Number * Complaint * Please state complaint with as much details as possible including dates, Rx number, member ID, etc. Pharmacy Fax Pharmacy Email * Select Request Type Provider Agreement Copy of Provider Manual PSAO Agreement Other (please email providers@prodigyrx.com) Additional Comments Thank you!
