Coverage Determination

Enrollee's Information

Enrollee's Name !        Date of Birth (mm/dd/yy) !

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 prescriber:

Requestor's Information

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 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 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.

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).

Supporting Information for an Exception Request or Prior Authorization

FORMULARY 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

Diagnosis and Medical Information

Medication:

Strength and Route of Administration:

Frequency:

New Prescription OR Date Therapy Initiated:

Expected Length of Therapy:

Quantity:

Height/Weight:

Drug Allergies:

Diagnosis:

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

Signature of person requesting the coverage determination (the enrollee, or the enrollee’s prescriber or representative):

Signature ! Signature Type

Date: