FORMULARY BENEFITS DATA CONSENTS FORM

Formulary Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan.

By signing below I give permission for Maryland Pain Specialists to access my pharmacy benefits data electronically through RxHub. This consent will enable Maryland Pain Specialists to:

Determine the pharmacy benefits and drug copays for your health plan.

Check whether a prescribed medication is covered (in formulary) under your plan.

Display therapeutic alternatives with preference rank (if available) within a drug class for non-formulary medications.

Determine if your health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies.

Download a historic list of all medications prescribed for you by any provider.

In summary, we ask your permission to obtain formulary information, and information about other prescriptions prescribed by other providers using RxHub.

Pharmacy name

Pharmacy phone number

Street address

City

State

Zip code

Patient's Authorization and Signature

I have carefully read this and have had an opportunity to ask any questions I might have had. I consent and agree that you can obtain my pharmacy information as set out above.

I request that payment of authorized insurance benefits be made either to me or on my behalf to Maryland Pain Specialists. I authorize any holder of medical information about me to release to the insurance company and its agents any information needed to determine these benefits or the benefits for related services.

PATIENT INFORMATION

FORMULARY BENEFITS DATA CONSENTS FORM

Patient's Authorization and Signature