Request for Prescription Drug Coverage Determination

To initiate a coverage review request, please complete the form below and click submit.

Please note that the completion of this form does not constitute completion of the coverage review process and is not a guarantee of plan coverage. Upon receipt of this request, we will begin the coverage review process for the medication indicated below.

Once the completed form is submitted, the patient or his/her representative or prescriber may be contacted by fax or phone for additional information.

You have either incorrectly entered information or have left some requested fields below blank. Please enter the required information below in order to continue submitting your coverage review request online.

Enrollee/Requestor Information

Enrollee’s Name*:


First Name	Middle Initial	Last Name

Date of Birth*:


mm	dd	yyyy

Address 1:

Address 2:

City:

State:

ZIP Code:

Phone*:

Enrollee’s Member ID Number*:

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

Requestor’s Name:


First Name	Middle Initial	Last Name

Requestor’s Relationship to Enrollee:

Address 1:

Address 2:

City:

State:

ZIP Code:

Phone:

Representation documentation for requests made by someone other than the enrollee or the enrollee's prescriber:

For Medicare Part D Members:

You will need to provide documentation showing the authority to represent the enrollee (a completed Appointment of Representative Form CMS - 1696 or written equivalent). To access the Appointment of Representative Form CMS - 1696, visit: https://www.cms.gov/cmsforms/downloads/cms1696.pdf

Prescriber’s Information

Name*:

Address 1*:

Address 2:

City*:

State*:

ZIP Code*:

Phone*:

Fax*:

National Provider Identifier (NPI):

*Indicates required fields

Name of prescription drug you are requesting

Drug Name*:
Drug Strength*:
Quantity requested per month:

*Indicates required fields

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: Not all plans allow for all types of reviews. 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. Please refer to the supporting information instructions below.

Additional information

Additional information we should consider:

Important Note: Expedited Decisions

Do you or your prescriber believe that waiting 72 hours or more for a decision could seriously harm your life, health to regain maximum function?

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS. Please follow the supporting information instructions below.

Supporting information

Please send any supporting information to our toll-free fax number at 1.877.251.5896 and be sure to include your name and telephone number on each page sent.

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Request for Prescription Drug Coverage Determination

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You must provide your email address below to complete this request. This email address is only for the use of this coverage request and will not be used for other purposes.

If you do not wish to submit this request online, call us toll-free at 1.800.753.2851, 24 hours a day, 7 days a week. For the hearing impaired with a TTY machine, please call 1.800.716.3231.

An email will be sent to the email address provided below, regardless of your personal email preference settings in your profile.

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*indicates required fields

Request for Prescription Drug Coverage Determination

Thank you for your request!

By clicking the "Print request" button below, you may download a copy for you records.

Print Request Done

Request for Prescription Drug Coverage Determination

Enrollee Information
Enrollee Name:	John Doe
Date of Birth:	01/04/1948
Address 1:	67 Abc Ave.
Address 2:	-
City:	Holmdel
State:	NJ
Zip Code:	07764
Phone:	-
Enrollee's Member ID Number*:	56337906

Requestor Information
Requestor's Name:	N/A
Requestor's Relationship to Enrollee:	-
Address 1:	-
Address 2:	-
City:	-
State:	-
Zip Code:	-
Phone:	-

Prescriber's Information
Name:	-
Address 1:
Address 2:	-
City:
State:	-
Zip Code:	-
Office Phone:
Fax:	-
National Provider Identifier (NPI):	-

Name of prescription drug you are requesting
Drug Name:	Lipitor
Drug Strength:	10mg
Quantity requested per month:	-

Type of Coverage Determination Request
Yes, I need a drug that is not on the plan's list of covered drugs (formulary exception). Yes, 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).

Additional information
Any additional information request goes here.

Supporting information
Please send any supporting information to our toll-free fax number at 1.877.251.5896 and be sure to include your name, telephone number on each page sent.

We are sorry, but we cannot complete your request at this time. Please try again later. You may also contact customer service at 800-935-6103

This page was last updated on 06/02/2023.

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