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

Request For Medicare Prescription Drug Coverage Determination Form Page 3

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.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS (if you

have a supporting statement from your prescriber, attach it to this request).

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:

Y0086_PTD213 CMS approved 12292011

Request For Medicare Prescription Drug Coverage Determination Form Page 3