Medicare Part D Coverage Determination Request Form printable pdf download

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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 OR See links to plan websites at

Patient Information

Prescriber Information

Patient Name:

Prescriber Name:

Member ID#:

NPI # (if available):

Address:

City:

State:

City:

State:

Home Phone:

Zip:

Office Phone#:

Office Fax#:

Zip:

Sex (circle one):

DOB:

Contact Person:

Diagnosis and Medical Information:

Medication:

Strength and Route of Administration:

Frequency:

□

Expected length of Therapy:

Qty:

New Prescription OR

Therapy Initiated:

Height/Weight:

Drug Allergies:

Diagnosis:

Prescriber’s signature:

Date:

Rational 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

Medicare Part D Coverage Determination Request Form

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