Please complete one form per Medicare Prescription Drug you are requesting a Coverage Determination for.
This form may also be sent to us by mail or fax:
Address:
CVS Caremark
Appeals Dept.
MC109
PO Box 52000
Phoenix AZ 85072-2000
Fax: 1-855-633-7673
You may also ask us for a coverage determination by phone at 1-844-812-6896, or through our website www.nhpri.org/Medicare-Medicaid/PharmacyBenefits/2019PharmacyBenefits.aspx.
Call Member Services at 1-844-812-6896 (TTY/TDD 711), 8 am to 8 pm, Monday – Friday; 8 am to 12 pm on Saturday. On Saturday afternoons, Sundays and holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.
For questions regarding the coverage determination process, please call the customer support number on your prescription card.
Enrollee's Information
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.
* Indicates required information.
Requestor Information (if not Enrollee - Prescriber, Family Member or Friend)
Complete the following section ONLY if the person making this request is not the enrollee or prescriber:
** 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 Representative Form CMS -1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare
Prescription drug you are requesting:
Important Note: Expedited Decisions
Supporting Information for an Exception Request or Prior Authorization
Prescriber Information
Diagnosis and Medical Information
Attachments (JPG, PDF, or TIF up to 10 megabytes)
You can submit up to five (5) attachments as supporting documentation. Limit 10 megabytes allowed per prescription drug coverage determination request. If you have other drugs you would like to request a coverage determination request for, please submit a form for each. To save your document into a .jpg or a .tif, go to file, save as, and save it with the extension of your choice. If you are scanning in a document, it is possible your scanner will save it in a .pdf format.
An electronic signature is required on this request. Clicking the grey submit button below, will serve as your electronic signature.