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Request for Medicare Prescription Drug Coverage Determination/Formulary Exception

Please complete this form and click the submit button to send this form.

Member's/Requestor's information (as it appears on the member's ID card):

Are you the member?

NOTE: If you are not the member or the member's prescribing physician or other prescriber, you must fax a signed Appointment of Representative form (or equivalent notice) to 1-800-693-6703 (toll free). You can also attach the signed Appointment of Representative form below. For more information on how to appoint a representative, please refer to your plan benefits materials.

If you are asking for a formulary or tiering exception, your PRESCRIBING PHYSICIAN must provide a statement to support your request.

You cannot ask for a tiering exception for a drug in the plan's Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to generic drugs. See your benefit materials for more information.

Do you want to attach a signed Appointment of Representative form?
No attachments
Name of prescription drug you are requesting (if known, include strength and quantity requested):

Is the brand or generic medication being requested?
How frequently do you take this drug?
Are you currently taking this drug?
Have you taken any other drug(s) for this same condition?
Prescribing physician information:

Type of Coverage Determination request:

Please select the option below that best describes your request
Do you want to attach any additional information?
No attachments
If you or your prescribing physician believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life or health or ability to regain maximum function, you can ask for and we will give you an expedited (fast) decision within 24 hours.