Request for Prescription Drug Coverage Determination

To submit this form electronically through our website, please complete the required fields below.

Required fields are denoted with a red astrisk (*)

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*
Date of Birth*
Enrollee's Address*
City*
State*
Zip Code*
Phone*
Enrollee's Member ID #*

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:
Requestors's Name
Requestors's Relationship to Enrollee
Requestors's Address
City
State
Zip Code
Phone

Representation documentation for 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). For more information on appointing a representative, contact your plan or 1-800-Medicare. If Applicable.

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

Type of Coverage Determination Request*
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 copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).*
I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).*
My drug plan charged me a higher copayment 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 attached "Supporting Information for an Exception Request or Prior Authorization" to support your request.
Additional information we should consider (attach any supporting documents):


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.

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).

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.

REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify that applying the 72 hour standard review timeframe may seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.

Prescriber's Information
Name*
Address*
City*
State*
Zip Code*
Office Phone*
Fax*
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
Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure [Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) 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 [Specify below: Anticipated significant adverse clinical outcome]
Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason]
Request for formulary tier exception [Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome]
Other

Required Explanation


Attachments
You may attach up to three documents to support your redetermination request. Accepted file types are doc, docx, and pdf.

Attachment #1:
Attachment #2:
Attachment #3: