prescription_drug_coverage_request

  1. Prescription Drug Coverage Request
  2. Prescription Drug Coverage Request for Medicare Members - Member Information
  3. Prescription Drug Coverage Request for Medicare Members - Doctor/Prescriber Information

Prescription Drug Coverage Request

*Required Field

Response Time

Your request will be reviewed within 72 hours, unless you specify that you need a faster response.

If you or your doctor/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 within 24 hours.

- If your doctor/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 doctor/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.

Need a faster response

Member's Authorized Representative Requirements

If you are someone other than the member or doctor/prescriber, we require an authorization to be on file. If not already on file, please complete an Authorization of Representation Form CMS-1696 or a written equivalent and Fax to 1-800-956-2397. For more information on appointing a representative, call Customer Services at the phone number on your Member ID Card. If you are a Medicare member, you may also call 1-800-Medicare.gov.

Please tell us who you are

Your Name

First and Last Name

Phone Number

###-###-####

Best Time to call

Include Day and Time (time between 00:00and 23:59)

Name of the Prescription Drug You are Requesting

Prescription Drug Name

Prescription Strength

Strength in MG, ML, etc. NA if not applicable

Prescription Quantity/Month

Quantity/Month. NA if not applicable

Medical Justification for Your Request

Member Information


 

Member Name

First and Last Name

Date Of Birth

mm/dd/yyyy

Subscriber ID

9 digit number or 'M' followed by 8 digits

Street Address 1

Street Address/P.O. Box

Street Address 2

Apartment/Suite/Unit/Building/Floor

City

State

Zip Code

5 digit zip code

Phone Number

###-###-####

Best Time to Call

Doctor/Prescriber Information


 

Doctor/Prescriber Name

First and Last Name

Specialty

Doctor/Prescriber Specialty

Street Address 1

Street Address/P.O. Box

Street Address 2

Apartment/Suite/Unit/Building/Floor

City

State

Zip Code

5 digit zip code

Phone Number

###-###-####

Fax Number

###-###-####

Doctor/Prescriber NPI#

NPI# (10 digit number)

Doctor/Prescriber DEA#

DEA# (2 letters followed by 7 numbers)