Please complete for all Medicare Prescription Drugs you are requesting a Coverage Determination for.

This form may also be sent to us by mail or fax:

Address:

Appeal Department
PO Box 52000
MC109
Phoenix, AZ 85072-2000

Fax: 1-855-633-7673

For questions regarding the coverage determination process, please call the customer support number on your prescription card.

Enrollee's Information

 
 
 
(mm/dd/yyyy)  

* Indicates required information.

Requestor Information (if not Enrollee): Prescriber, Family Member or Friend

Who may make a request: You can fill out and submit this request yourself, or 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 designated as your representative. Contact us to learn how to name a representative.
Call Customer Service at 1-888-648-9622 (TTY users call 1-866-236-1069). You can call 24 hrs. daily, local time.

Complete the following section ONLY if the person making this request is NOT the enrollee:
** 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 (1-800-633-4227), 24 hrs. a day, 7 days a week. TTY users call 1-877-486-2048.

Prescription drug 1 you are requesting:

Have you purchased the drug pending appeal?
 

Prescription drug 2 you are requesting:

Have you purchased the drug pending appeal?
 

Prescription drug 3 you are requesting:

Have you purchased the drug pending appeal?
 









* Note: If you are asking for a formulary or tiering exception, your prescribing physician MUST provide a statement to support your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may also use the "Supporting Information for an Exception Request or Prior Authorization" to support your request.

Important Note: Expedited Decisions Must Have Prescriber’s Supporting Statement

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.