Request for Medicare Prescription Drug Coverage Determination

1. Member's Information

Name:*

First Last

Address:

Address line 1 Address line 2 City State ZIP code

Phone:

Date of birth:*

Member's plan ID:*

2. Requestor's Information

Complete this section only if the person making the request is not the member or the prescribing doctor.

Name:

First Last

Your relationship to the member:

Address:

Address line 1 Address line 2 City State ZIP code

Phone:

Representation documentation for requests made by someone other than enrollee or the enrollee’s prescribing doctor: 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.
Use the Select files button at the bottom of this form to attach documentation.

3. Prescription information

What is the name of the prescription drug you are requesting? If known, please include strength and quantity requested per month.

Prescription Information:*

4. Type of Coverage Determination Request

Please chose one:*

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 an exception to the requirement that I try another drug before I get the drug my doctor prescribed (formulary exception).*
I request prior authorization for the drug my doctor has prescribed.
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 doctor prescribed (formulary exception).*
My drug plan charged me a higher copay for a drug than it should have.
My drug plan charges a higher copay for the drug my doctor prescribed than it charges for another drug that treats my condition, and I want to pay the lower copay (tiering exception).*
I have been using a drug that was previously included on a lower copay tier, but is being moved to or was moved to a higher copay tier (tiering exception).*
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 prescribing doctor MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information.

Additional information we should consider: (you may also attach any supporting documentation using the Select files button at the bottom of this form):

Please attach any relevant documents

Drop files here or

If you or your prescribing doctor believe that waiting for 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 prescribing doctor indicates that waiting 72 hours could seriously harm your life or health, we will give you a decision within 24 hours. If you do not obtain your prescribing doctor'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 prescribing doctor, attach it to this request).

Email: Please enter your email address to receive a confirmation email of your online request.

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