Get Prescription Drug Coverage Determination Request Form. Prescription Drug Coverage Determination

Filling out the Prescription Drug Coverage Determination Request Form is an important step in ensuring that you receive the necessary medication coverage. This guide will walk you through the required sections and provide clear instructions to help you complete the form accurately.

Follow the steps to complete your coverage determination request.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the enrollee's information. Provide the full name, date of birth, address, city, state, zip code, phone number, and member ID number.
3. If someone other than the enrollee or prescriber is making the request, fill out the requestor's information, including their name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. Include representation documentation if applicable. Attach any necessary documents that show the authority of the requestor to represent the enrollee.
5. Specify the name of the prescription drug you are requesting, including the strength and quantity requested per month, if known.
6. Indicate the type of coverage determination request by checking the appropriate box related to your need, such as formulary exception or prior authorization.
7. Provide additional information we should consider by attaching any supporting documents that may strengthen your request.
8. If expedited decision is needed, check the appropriate box and ensure a supporting statement from your prescriber is attached.
9. Sign and date the form to confirm the request is accurate and complete.
10. Complete the prescriber’s information section, if applicable, including the name, address, office phone, and signature.
11. After filling out all sections, save changes, download, print, or share the form as needed.

Start the process now by completing your Prescription Drug Coverage Determination Request Form online.