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

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 Information


 

Member Name

Date Of Birth

Subscriber ID

Street Address 1

Street Address 2

City

State

Zip Code

Phone Number

Best Time to Call

Doctor/Prescriber Information


 

Doctor/Prescriber Name

Specialty

Street Address 1

Street Address 2

City

State

Zip Code

Phone Number

Fax Number

Doctor/Prescriber NPI#

Doctor/Prescriber DEA#