MDR Pharmaceutical Care: Fertility Medications

Many patients believe their insurance does not cover fertility medications. Our successful insurance specialist team often finds coverage patients didn't know existed. MDR's reimbursement experts will verify your insurance at no charge and no obligation to you. Please fill out the form below for your pharmacy benefit verification. (Please note: your physician's prescription is required for verification process.)

PHARMACY BENEFIT VERIFICATION FORM

Fields marked * are required to be filled

*Name Last:

*First:

SSN:

*DOB:(mm/dd/yy)

Home Address:

City:

State:

Zip:

*E-mail:

*Home Phone:

Work Phone:

*Physician's Name:

Physician's Phone:

Procedure:

Generic Substitution?

Yes No

PRIMARY INSURANCE

*Policy Holder:

*Insurance Company:

*Ins Phone:

*Group#:

Policy#:
(if known)

*ID#:

If spouse is policyholder, the following are required (†):

†Spouse Name:

†Spouse SSN:

†Spouse DOB:

(mm/dd/yy)

SECONDARY INSURANCE

Policy Holder:

Insurance Company:

Ins Phone:

Group#:

Policy#:
(if known)

ID#:

If spouse is policyholder, complete the following:

Spouse Name:

Spouse SSN:

Spouse DOB:

*Anticipated Start Date:		(mm/dd/yy)
*Date Medications Needed:		(mm/dd/yy)


ARC, the nation’s largest network of Reproductive Endocrinologists, offers unique fertility treatment packages, pharmaceutical packages, along with financing options which help patients overcome insurance coverage limitations. To find out how affordable it is to make your dreams come true or to find an ARC physician near you, click here www.arcfertility.com or call ARC’s toll free number, 1-888-990-2727, for fast and confidential service.