Request For Medicare Prescription Drug Coverage Determination

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User Manual: Request-for-Medicare-Prescription-Drug-Coverage-Determination

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This form may be sent to us by mail or fax:
Pharmacy Services
PO Box 1520 JAF Station
New York, NY 10116-1520

Fax Number:

You may also ask us for a coverage determination by phone at 1-877-444-3973 or through our
website at
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.
Enrollee’s Information
Enrollee’s Name _____________________________________ Date of Birth _______________
Enrollee’s Address _______________________________________________________________
City ___________________________ State______________ Zip Code _______________
Phone ___________________________ Enrollee’s Member ID # __________________________
Complete the following section ONLY if the person making this request is not the enrollee or
Requestor’s Name ____________________________________________________________
Requestor’s Relationship to Enrollee _____________________________________________
Address ____________________________________________________________________
City __________________________________ State ________ Zip Code ______________
Phone _____________________________
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.

Name of prescription drug you are requesting (if known, include strength and quantity
requested per month):

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
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: 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: Expedited Decisions
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.
a supporting statement from your prescriber, attach it to this request).
Signature of person requesting the coverage determination (the enrollee, or the
enrollee’s prescriber or representative):

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
Name _________________________________________________________________________
Address _______________________________________________________________________
City ____________________________________ State _______ Zip Code _________________
Office Phone_____________________________ Fax __________________________________
Prescriber’s Signature ______________________________________ Date________________
Diagnosis and Medical Information
Strength and Route of Administration:
New Prescription OR Date
Therapy Initiated:

Expected Length of Therapy:

Drug Allergies:



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)
Required Explanation:___________________________________________________________

H6864_MMG14_21_Coverage Determination_Accepted


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