Coverage Determination form

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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:

Appeals Department
MC109
P.O. Box 52000
Phoenix, AZ 85072-2000

Fax Number: 1-855-633-7673

You may also ask us for a coverage determination by phone 24 hours a day, 7 days a week by calling the telephone number on the back of your Blue MedicareRx id card.

All fields are optional unless marked required.

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.

Enrollee's first name (required)

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Enrollee's last name (required)

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Enrollee's phone number (required)

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Date of birth

Enrollee's street address

Unit, apartment, etc

City

State

Zip Code

Enrollee's Member ID

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

Requestor's First Name (Optional)

Requestor's Last Name (Optional)

Relationship to Enrollee ¹ (Optional)

Phone Number (Optional)

Street Address (Optional)

City (Optional)

State (Optional)

ZIP Code (Optional)

¹Representation 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. You may also sign and date and fax the Blue MedicareRx (PDP) Appointment of Representative form. Back

Prescription drug you are requesting:

Name of Drug

Strength/quantity/dose:

Have you purchased the drug pending appeal?

Yes

Date purchased (Optional)

Amount paid: (Optional)

Type of Coverage Determination

Select all that apply.

I need a drug that is not on the plan’s list of covered drugs (formulary exception).²

I have been using a drug that was previously included on the plan’s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception). ²

I request prior authorization for the drug my doctor has prescribed.

I request an exception to the requirement that I try another drug before I get the drug my doctor prescribed (formulary exception).²

I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my doctor prescribed (formulary exception).²

My drug plan charges a higher copayment for the drug my doctor prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).²

I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).²

My drug plan charged me a higher copayment for a drug than it should have.

I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

²Note: 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. Back Back Back Back Back Back

Additional information we should consider (attach any supporting documents at the bottom of the form):

Max characters: 500

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.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS (if you have a supporting statement from your prescriber, attach it to this request).

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.

REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify that applying the 72 hour standard review timeframe may seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.

Prescriber Information

First Name (Optional)

Last Name (Optional)

Phone Number (Optional)

Fax Number (Optional)

Sreet Address (Optional)

City (Optional)

State (Optional)

Zip Code (Optional)

NPI # (Optional)

Diagnosis and Medical Information

Medication (Optional)

Strength and route or administration: (Optional)

Frequency (Optional)

New prescription or Date therapy initiated: (Optional)

Expected length of therapy: (Optional)

Quantity: (Optional)

Height/Weight: (Optional)

Drug Allergies: (Optional)

Diagnosis: (Optional)

Rationale for Request

Select all that apply.

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure [Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)]

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change [Specify below: Anticipated significant adverse clinical outcome]

Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason]

Request for formulary tier exception [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]

Other (explain below)

Additional information we should consider (attach any supporting documents at the bottom of the form):

Max characters: 500

Attachments (JPG, PDF, or TIF up to 3 megabytes)

You can submit up to five (5) attachments as supporting documentation. Limit 3 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.

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