Medicare Prior Authorization Forms

Rocky Mountain cannot process prior authorization requests unless the physician sends clinical notes and indicated test results.  Failure to send clinical notes and test results will result in a timely denial of your request per Colorado State law.

 Medicare Part B Forms

Arzerra (ofatumumab)

Entyvio (vedolizumab)

Erbitux (cetuximab)

Eylea (aflibercept)

Halaven (eribulin)

Jetrea (ocriplasmin)

Kadcyla (ado-trastuzumab)

Kalbitor (escallantide)

Krystexxa (pegloticase)

Lucentis (ranibizumab)

Provenge (sipuleucel-T)

Soliris (eculizumab)

Testopel (testosterone pellet)

Xiaflex (collagenase clost hist)

Xofigo (radium Ra 223)

RMHP's contract with Medicare is renewed annually. The availability of coverage beyond the end of the current year is not guaranteed. RMHP has contracted with Medicare to provide benefits since 1977

This page was last updated: 10/1/2015.  Please call to confirm you have the most up to date information about our Medicare Cost plans. Medicare Disclaimers

RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. H0602_MS_MC400WEB_RMHP1 Approved