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

*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.

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

Need a faster response null

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.

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

Please tell us who you are

Your Name

Your Name First and Last Name null

Phone Number

Phone Number ###-###-#### null

Best Time to call

Best Time to call Include Day and Time (time between 00:00and 23:59) null

Name of the Prescription Drug You are Requesting

Name of the Prescription Drug You are Requesting Prescription Drug Name null

Prescription Strength

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

Prescription Quantity/Month

Prescription Quantity/Month Quantity/Month. NA if not applicable null

Medical Justification for Your Request

Medical Justification for Your Request null

Member Information


 

Member Information


 

Member Name

Member Name First and Last Name null

Date Of Birth

Date Of Birth mm/dd/yyyy null

Subscriber ID

Subscriber ID 9 digit number or 'M' followed by 8 digits null

Street Address 1

Street Address 1 Street Address/P.O. Box null

Street Address 2

Street Address 2 Apartment/Suite/Unit/Building/Floor

City

City null

State

State null

Zip Code

Zip Code 5 digit zip code null

Phone Number

Phone Number ###-###-#### null

Best Time to Call

Best Time to Call null

Doctor/Prescriber Information


 

Doctor/Prescriber Information


 

Doctor/Prescriber Name

Doctor/Prescriber Name First and Last Name null

Specialty

Specialty Doctor/Prescriber Specialty

Street Address 1

Street Address 1 Street Address/P.O. Box null

Street Address 2

Street Address 2 Apartment/Suite/Unit/Building/Floor

City

City null

State

State null

Zip Code

Zip Code 5 digit zip code null

Phone Number

Phone Number ###-###-#### null

Fax Number

Fax Number ###-###-#### null

Doctor/Prescriber NPI#

Doctor/Prescriber NPI# NPI# (10 digit number) null

Doctor/Prescriber DEA#

Doctor/Prescriber DEA# DEA# (2 letters followed by 7 numbers) null
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