Request Prescription Drug Coverage

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.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS.
If you have a supporting statement from your prescriber, attach it to this request.

Enrollee's Information

First Name

Last Name

ID Number

Date of Birth

Enrollee's Contact Information

Email Address

Phone Number

Street Address

Zip Code

City

State

Requestor's Contact Information

Complete the following section ONLY if the person making this request is not the enrollee:

First Name

Last Name

Relationship to Enrollee

Phone Number

Street Address

Zip Code

City

State

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) and enter a brief explanation below. For more information on appointing a representative, contact your plan or 1-800-MEDICARE.

Prescription Drug Requested

Name of prescription drug you are requesting (if known, include strength and quantity requested per month)

Type of Coverage Determination Request

Select at least one option from the list below.

I need a drug that is not on the plan's list of covered drugs (formulary exception)

I have been using a drug that was previously included on the plan's list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception)

I request prior authorization for the drug my prescriber has prescribed

I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception)

I request an exception to the plan's limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception)

My drug plan charges a higher co-payment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower co-payment (tiering exception)

I have been using a drug that was previously included on a lower co-payment tier, but is being moved to or was moved to a higher co-payment tier (tiering exception)

My drug plan charged me a higher co-payment for a drug than it should have

I want to be reimbursed for a covered prescription drug that I paid for out of pocket

NOTE: 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 "Supporting Information for an Exception Request or Prior Authorization" section below to support your request.

Additional information we should consider (attach any supporting documents).

Signature of person requesting the coverage determination (the enrollee, the enrollee's prescriber, or representative) and date are required upon submission.

Signature

Date

Supporting Information for an Exception Request or Prior Authorization

FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber's supporting statement. PRIOR AUTHORIZATION requests may require supporting information.

Prescriber's Information

First Name

Last Name

Phone Number

Fax Number

Street Address

Zip Code

City

State

Prescriber's Signature

Date

Diagnosis and Medical Information

Medication/Strength and Route of Administration

Frequency

Start Date

Expected Length of Therapy

Quantity

Weight

Height

Diagnosis

Drug Allergies

Rationale for Request

Select all that apply.

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure

Drug(s) contraindicated or tried

Adverse outcome for each

If therapeutic failure, length of therapy on each drug(s)

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change

Anticipated significant adverse clinical outcome

Medical need for different dosage form and/or higher dosage

Dosage form (s) and/or dosage(s) tried

Medical Reason

Request for formulary tier exception

Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug

If therapeutic failure, length of therapy on each drug and adverse outcome

If not as effective, length of therapy on each drug and outcome

Other (provide details)

* Explanation

Request Prescription Drug Coverage

Please correct the following errors:

Please correct the following errors

Enrollee's Information

Enrollee's Contact Information

Requestor's Contact Information

Prescription Drug Requested

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization

Prescriber's Information

Diagnosis and Medical Information

Rationale for Request

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Request Prescription Drug Coverage

Please correct the following errors:

Please correct the following errors

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Requested

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization ?

Prescriber's Information

Diagnosis and Medical Information

Rationale for Request

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Enrollee's Information

Requestor's Contact Information

Supporting Information for an Exception Request or Prior Authorization