Medicare Part D Coverage Determination Request Form

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Plan Name __________________________________
Phone # _________________________________________
Fax # ___________________________________________
Medicare Part D Coverage Determination Request Form
This form cannot be used to request:
Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight
gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
Biotech or other specialty drugs for which drug-specific forms are required. [See <Part D plan website.>] OR
[See links to plan websites at
Patient Information
Prescriber Information
Patient Name:
Prescriber Name:
Member ID#:
NPI# (if available):
Address:
Address:
City:
State:
City:
State:
Home Phone:
Zip:
Office Phone #:
Office Fax #:
Zip:
Sex (circle):
M
F
DOB:
Contact Person:
Diagnosis and Medical Information
Medication:
Strength and Route of Administration:
Frequency:
New Prescription OR
Expected Length of Therapy:
Qty:
Date Therapy Initiated:
Height/Weight:
Drug Allergies:
Diagnosis:
Prescriber’s Signature:
Date:
Rationale for Exception Request or Prior Authorization
FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION
Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, 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);
Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) 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:________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Request for Expedited Review
REQUEST FOR EXPEDITED REVIEW [24 HOURS]
BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR
STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE
MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION
Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

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