REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
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.
Fields marked with yellow background are mandatory fields.
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).
(**Attachments not available in the online form, refer to PDF form)
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
requestsmay 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.