Request For Medicare Prescription Drug Coverage Form (Page 3 of 4) in pdf

Request For Medicare Prescription Drug Coverage Form Page 3

Signature of person requesting the coverage determination (the enrollee, or the

enrollee’s prescriber or representative):

Date:

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.

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 __________________________________

Prescriber’s Signature ______________________________________ Date________________

Diagnosis and Medical Information

Medication:

Strength and Route of Administration:

Frequency:

New Prescription OR Date

Expected Length of Therapy:

Quantity:

Therapy Initiated:

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)]

Request For Medicare Prescription Drug Coverage Form Page 3