Member Instructions for Sending the Member Drug Error Report
Print Form
Reset Form
Date/Time Received by MRx Quality:
Tracking # Assigned:
Member Drug Error Report
Pharmacy name where drug was received: Date the drug was received:
Date drug error was identified: Date Error Reported to Magellan Rx Management:
Definitions
Drug Error
What does this mean? Any mistake in the drug you received that is different from what your doctor wrote. Examples include: received a drug my doctor did not order for me, received the wrong drug; received the wrong dose of the drug, received the wrong dosage form of the drug such as pill when liquid was ordered, received another person's drug, received too many pills, did not receive enough pills, received a drug that had expired, received a drug that was not stored at the right temperature,
Member Demographics
Member Name
Member ID
Member Plan
Patient Member was the patient. Member was NOT the patient.
If the member was not the patient (intended recipient of the medication) please enter the following:
Intended Recipient's Name
Age
Relationship to Member
Complete the following information regarding the drug:
Drug Name Pharmacy Rx Number on Bottle Ordering Doctor
Proprietary & Confidential ? 2015-2022 Magellan Rx Management, LLC. All rights reserved.
Please provide a narrative description of all the events surrounding the drug error. Please answer to the best of your ability all the questions below. You may use more paper.
Questions
Description
How was the mistake found?
Was the mistake found before the
YES
I do not know
NO
member (or the patient) took their
first dose?
If NO, how many doses were taken?
Was your doctor told?
YES Date:
NO
If NO, please indicate the reason why.
Did the member (or the patient) have NO
I do not know
YES
anything bad happen because of
taking the drug?
If YES, please give details.
Did the member (or the patient) see a NO
I do not know
YES
doctor because of what happened?
If YES, please give more details
Was your pharmacy told they had
YES Date:
NO
made a mistake?
If NO, please indicate the reason why.
Did the member (or the patient) later YES Date:
NO
get the correct drug?
If NO, please explain.
Name of Person Completing Form:
Can we call you if we have questions? NO YES
Telephone Number:
Best Days and Time(s) to Call:
Thank you for completing this form. To make sure we receive this report, please send the completed form to Magellan Rx Management by web, email, or mail as outlined in the instructions provided on our website. Email and address are also noted below:
Email: MRxQualityDepartment@ Mail: Magellan Rx Management
Attention Quality Department 11013 W. Broad St, Suite 500 Glen Allen, VA 23060
Page 2 | Member Drug Error Report
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- dmas new pharmacy benefit administration frequently asked questions faqs
- magellan rx management provider manual
- dmba medical pharmacy program
- connecticut aids drug assistance program adap ncpdp d 0 payer
- member instructions for sending the member drug error report
- important notice qualchoice
- magellan rx commercial ncpdp d 0 payer specifications
- michigan ncpdp d 0 payer specifications magellan rx management
- mrx caterpillar ncpdp d 0 payer specifications magellan rx management
- pbm bins help desk pba health
Related searches
- nature medicine instructions for authors
- cane walking instructions for patients
- email instructions for beginners
- scientific reports instructions for authors
- zicam instructions for use
- nature instructions for authors
- yahoo email instructions for beginners
- nature journal instructions for authors
- tablet instructions for dummies
- instructions for schedule d irs
- instructions for schedule a
- nature communications instructions for authors