Enrollee's Information


      



               

      


Complete the following section ONLY if the person making this request is not the enrollee or prescriber:


Requestor's Information








               



Representation documentation for requests made by someone other than enrollee or the enrollee’s prescriber:

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare.


Name of prescription drug you are requesting (if known, include strength and quantity requested per month):

Type of Coverage Determination Request









*NOTE: If you are asking for a formulary 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.


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.



Supporting Information for an Exception Request or Prior Authorization

FORMULARY EXCEPTION requests cannot be processed without a prescriber’s supporting statement. PRIOR AUTHORIZATION requests may require supporting information.



Prescriber's Information


  

  

                     

           

Diagnosis and Medical Information


Rationale for Request









Signature of person requesting the coverage determination (the enrollee, or the enrollee’s prescriber or representative):


                           

Date: