Step 1 - Beneficiary Information

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.

 
 

 

 
 
 
 

 

 

Check this option ONLY if the person making this request is not the enrollee or prescriber

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

 
 
 
 
 

 

 

Representation documentation for requests made by someone other than enrollee or the enrollee’s prescriber
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.

Step 2 - Medication Information

Name of prescription drug you are requesting

 

Step 3 - Type of Request

Type of Coverage Determination Request









 

Provide any explanation regarding your selection:

*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. Your prescriber may use the attached “Supporting Information for an Exception Request or Prior Authorization” to support your request.

Additional information we should consider (attach any supporting documents):

Important Note: Check this box if you require an expedited decision

Important Note: Expedited Decision If you or your doctor believe that waiting 72 hours for a standard decision could seriously affect your life, health or ability to regain maximum function, you You can request an expedited (fast) decision. If your doctor indicates that waiting 72 hours seriously affect your health, the Plan will automatically provide a decision within 24 hours. If you do not get medical support for an expedited request, we will decide if your case merits a quick decision. You can not apply for a expedited coverage determination if you request reimbursement for drugs you already received.

If you have medical justification, attach it to this application.

Step 4 - Supporting Information


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 requests may 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.

Prescriber’s Information







Information and diagnostics

Diagnosis and Medical Information

Rationale for Request

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure


[Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)]

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change


[Specify below: Anticipated significant adverse clinical outcome]

Medical need for different dosage form and/or higher dosage


[Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason]

Request for formulary tier exception


[Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome]

Other


(Explain below)