Loading... Please Wait
Eform
*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
Phone Number
Best Time to call
Name of the Prescription Drug You are Requesting
Prescription Strength
Prescription Quantity/Month
Medical Justification for Your Request
Member Name
Date Of Birth
Subscriber ID
Street Address 1
Street Address 2
City
State
Zip Code
Best Time to Call
Doctor/Prescriber Name
Specialty
Fax Number
Doctor/Prescriber NPI#
Doctor/Prescriber DEA#