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