Request for Medicare Prescription Drug Coverage Determination

 
* = Required
Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.
Enrollee's Information
Enrollee's Name*  
Enrollee's Member ID*
DOB (MM/DD/YYYY)*
Enrollee's Address*
Enrollee's City*
Enrollee's State*
Enrollee's Zip*
Enrollee's Phone Number*   Ext.
 
Requestor Information
Complete the following section ONLY if the person making the request is not the enrollee or prescriber.
Requestor's Name  
Requestor's Relationship to Enrollee
Requestor's Address
Requestor's City
Requestor's State
Requestor's Zip
Requestor's Phone Number   Ext.

 
Representation documentation for appeal requests made by someone other than enrollee or the enrollee's prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.

Name of prescription drug you are requesting (if known, include strength and quantity requested per month):*  
 
Type of Coverage Determination Request*





 
1NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached “Supporting Information for an Exception Request or Prior Authorization” to support your request.
 
Additional information we should consider
 
Important Note: Expedited Decisions
If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
 
(if you have a supporting statement from your prescriber, attach it to this request).
Signature* Date

Supporting Information for an Exception Request or Prior Authorization

Prescriber's Information
Prescriber's Name  
Prescriber's Address
Prescriber's City
Prescriber's State
Prescriber's Zip
Prescriber's Phone Number   Ext.
Prescriber's Fax Number
Prescriber's Signature: Date:
 
Diagnosis and Medical Information
Medication  
Strength and Route of Administration
Frequency
New Prescription OR Date Therapy Initiated
Expected Length of Therapy
Quantity
Height/Weight
Drug Allergies
Diagnosis
 
Rationale for Request





  Required Explanation: