Request for Medicare Prescription Drug Coverage Determination

This request can be submitted online by selecting
the Submit button at the bottom of this page.

If you do not wish to submit the request online, this form may be sent to us by mail or fax:
ADDRESS FAX NUMBER
P.O. Box 1039, Appleton, WI 54912-1039
1-855-668-8552

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


COMPLETE THIS 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 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. Your prescriber may use the attached 'Supporting Information for an Exception Request or Prior Authorization' form to support your request.



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 have already received.



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 INFORMATION


DIAGNOSIS AND MEDICAL INFORMATION

DIAGNOSIS - Please list all diagnoses being treated with the requested drug and corresponding ICD-10 codes.
(if the condition being treated with the requested drug is a symptom e.g. anorexia, weight loss, shortness of breath, chest pain, nausea, etc., provide the diagnosis causing the symptom(s) if known)"




mg/day

RATIONALE FOR REQUEST