Request For Medicare Prescription Drug Coverage Determination Form (Page 2 of 4) in pdf

Request For Medicare Prescription Drug Coverage Determination Form Page 2

Name of prescription drug you are requesting (if known, include strength and quantity

requested per month):

Type of Coverage Determination Request

I need a drug that is not on the plan’s list of covered drugs (formulary exception).*

I have been using a drug that was previously included on the plan’s list of covered drugs, but is

being removed or was removed from this list during the plan year (formulary exception).*

I request prior authorization for the drug my prescriber has prescribed.*

I request an exception to the requirement that I try another drug before I get the drug my

prescriber prescribed (formulary exception).*

I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so

that I can get the number of pills my prescriber prescribed (formulary exception).*

My drug plan charges a higher copayment for the drug my prescriber prescribed than it

charges for another drug that treats my condition, and I want to pay the lower copayment (tiering

exception).*

I have been using a drug that was previously included on a lower copayment tier, but is being

moved to or was moved to a higher copayment tier (tiering exception).*

My drug plan charged me a higher copayment for a drug than it should have.

I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

*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” to support your request.

Additional information we should consider (attach any supporting documents):

Y0086_PTD213 CMS approved 12292011

Request For Medicare Prescription Drug Coverage Determination Form Page 2