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Request for Medicare Prescription Drug Coverage Determination

Please complete the fields below to submit an online request for a Medicare Prescription Drug Coverage Determination. Fields marked with an asterisk (*) are required.

Request for Medicare Prescription Drug Coverage Determination

1Please enter your information below.
2Please confirm your information is correct.
  • 1. Member's Information

  • MM slash DD slash YYYY
  • 2. Requestor's Information

    Complete this section only if the person making the request is not the member or the prescribing doctor.
  • 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.
  • 4. Type of Coverage Determination Request

  • * 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.
  • Drop files here or
    Accepted file types: pdf, doc, docx, txt, Max. file size: 64 MB, Max. files: 3.
    • 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.

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