Medicare Part D Coverage Determination Request Form printable pdf download

Plan Name __________________________________

Phone # _________________________________________

Fax # ___________________________________________

Medicare Part D Coverage Determination Request Form

This form cannot be used to request:

Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight

gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

Biotech or other specialty drugs for which drug-specific forms are required. [See <Part D plan website.>] OR

[See links to plan websites at

Patient Information

Prescriber Information

Patient Name:

Prescriber Name:

Member ID#:

NPI# (if available):

Address:

City:

State:

City:

State:

Home Phone:

Zip:

Office Phone #:

Office Fax #:

Zip:

Sex (circle):

DOB:

Contact Person:

Diagnosis and Medical Information

Medication:

Strength and Route of Administration:

Frequency:

New Prescription OR

Expected Length of Therapy:

Qty:

Date Therapy Initiated:

Height/Weight:

Drug Allergies:

Diagnosis:

Prescriber’s Signature:

Date:

Rationale for Exception Request or Prior Authorization

FORM CANNOT BE PROCESSED WITHOUT REQUIRED EXPLANATION

Alternate drug(s) contraindicated or previously tried, but with adverse outcome (eg, 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);

Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) 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

REQUIRED EXPLANATION:________________________________________________________________

_______________________________________________________________________________________

Request for Expedited Review

REQUEST FOR EXPEDITED REVIEW [24 HOURS]

BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR

STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE

MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION

Information on this form is protected health information and subject to all privacy and security regulations under HIPAA.

Medicare Part D Coverage Determination Request Form

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