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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.

 

Enrollee/Requestor Information

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

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

*Indicates required fields

 

Name of prescription drug you are requesting

*Indicates required fields

 

Type of Coverage Determination Request

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. Please refer to the supporting information instructions below.

 

Additional information

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?