Medication Coverage Request Form Medicare Part D Coverage Determination Request Form

Or fill out online form below

Request for Medicare Prescription Drug Coverage Determination

Enrollee's Information

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 the 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.

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. The section below titled “Supporting Information for an Exception Request or Prior Authorization” can be used by your provider to support your request.

Additional information for consideration can be faxed to (858) 357-2582

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.

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.

Prescriber's Information
Diagnosis and Medical Information
Rationale for Request

Fax supporting documents (clinic notes, labs, etc) to (858) 357-2582

*Indicates a required field

**Prescribers will be notified by fax and members will be notified by mail when a decision has been determined.**