You may also ask us for a coverage determination by phone at 1-877-436-5288 or through our website at We are available 8:00 a.m. – 8:00 p.m., 7 days a week. TTY/TDD users should call 711.
Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee's Information

Enrollee's Name          Date of Birth  

Enrollee's Address  

City           State        Zip Code  

Phone        Enrollee’s Member ID # 

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

Requestor's Name

Requestor's Relationship to Enrollee


City         State       Zip Code


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 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):

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

Prescriber's Information



City          State         Zip Code  

Office Phone         Fax  

Diagnosis and Medical Information
Strength and Route of Administration:
New Prescription OR Date Therapy Initiated:
Expected Length of Therapy:
Drug Allergies:

Rationale for Request
 [Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)]
 [Specify below: Anticipated significant adverse clinical outcome]
 [Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason]
 [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
 (explain below)

Required Explanation

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

Signature   Signature Type
Date:   6/13/2024