Medicare SWAT & Issue Case Specific Inquiry Request

Instructions: Please fill out the form with all information necessary for the Medicare Pharmacy Team to investigate this inquiry. You will receive an email from the APM Medicare Team Member assigned to your issue, as they begin working towards resolution. * Denotes a Required Field

Inquiry Type Information

Inquiry Type

Case Title

Priority Level

1-Catastrophic Catastrophic/ significant business disruption in adjudication. 2-Critical Major client or participant impacts but limited to smaller member impacts in adjudication. Examples: An entire plan or group cannot process claims. Resolve in 48 hours 3-Significant Moderate client or participant impacts Example: A plan or group has an issue with a plan edit. Resolve or work-around established in 72-96 hours 4-Routine Low client or participant impacts Resolve or work-around established within 1 week

SWAT MED-D issue?

YesNo

Select Yes to indicate if this is a Med D SWAT case. If not a SWAT MED-D case, select the Webform option for the Case Origin field.

Case Origin

Plan Sponsor Information

Plan Sponsor Name

PSU Unique ID

RxPlanID(s)

Please separate individual RxPlanID's using a comma.

Your Contact Information

Name

Email Address

Additional Email Address

Use this field if you need to enter a second email address for the Account Associate team to use when responding to this issue. DO NOT enter a member's email address in either email field.

Phone Number

Inquiry Information

Member Name

Do you have the member's Aetna/SSI ID Number?

YesNo

Member's Aetna/SSI ID number

Inquiry Description

Please provide detailed information including dates of service, medication names and all relevant information. Please attach any email communication and/or SWAT communication form, if applicable.

Attachment

[Please attach any additional documents that will assist in the review of this issue]