Medicare Agreement for Services
The Dartmouth-Hitchcock Health Retail Pharmacy Services can bill Medicare for services. Please see the Medicare Authorization/Agreement for Services form (DOCX) along with the Medicare Supplier Standards form and the Patient’s Rights and Responsibilities. This form allows the pharmacy to bill Medicare Part B for eligible prescriptions; without it, we are unable to bill Medicare Part B.
Medicare Prescription Drug Coverage Rights
The CMS Medicare Prescription Drug Coverage Rights (PDF) are the standardized notice, the content of which may not be altered. The notice is provided to the enrollee in 12-point font. The OMB control number must be displayed in the upper right corner of the notice. The fields for the enrollee’s name, drug, and prescription number are optional and may be populated by the pharmacy. You are required to distribute this enrollee notice as directed above; compliance with this process is required as per your Catamaran Participating Provider Agreement and Medicare Part D Addendum. Provision of this enrollee notice is an auditable requirement of pharmacy standards of practice related to the provision of Part D services.
CMS Likely to Benefit Notice
Consider managing your monthly drug costs with the Medicare Prescription Payment Plan. You might benefit from participating in the Medicare Prescription Payment Plan because you have high drug costs. Please see the CMS Likely to Benefit Notice (PDF).