Get Model Coverage Determination Request Form12013swrev.docx - Medicare Swhp

Filling out the Model Coverage Determination Request Form is an important step in requesting necessary medications under Medicare. This guide provides clear, step-by-step instructions to help users navigate the form efficiently.

Follow the steps to complete your coverage determination request form.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the enrollee’s information. This includes the enrollee’s name, date of birth, address, city, state, zip code, phone number, and member ID. Ensure that the information is accurate and up-to-date.
3. If the requestor is not the enrollee or their prescriber, complete the section for the requestor’s information. Provide their name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. Indicate the name of the prescription drug being requested, including the strength and quantity required per month when known.
5. Select the type of coverage determination request you are making. Options include 'formulary exception,' 'prior authorization,' 'quantity limit exception,' or 'tiering exception.' Make sure to check the relevant box that reflects your need.
6. If applicable, attach any supporting documents, including a prescriber’s statement or additional information that may assist in the evaluation of the request.
7. If you believe it is necessary to expedite the decision, check the appropriate box and ensure you include a supporting statement from the prescriber.
8. Obtain the prescriber’s information, including their name, address, city, state, zip code, office phone, and fax. Ensure the prescriber signs and dates the form.
9. Provide the diagnosis and medical information including medication details, height/weight, expected length of therapy, allergy information, frequency, and quantity.
10. In the rationale for request section, indicate any relevant details to support the necessity of the medication being requested, including alternate medications that have been tried.
11. Once all sections are completed, review the form for accuracy. Save any changes made, and use the available options to download or print the completed form for submission.
12. Submit the form either via mail or fax to Scott & White Health Plan at the address or fax number provided.

Complete your coverage determination request form online today to ensure timely access to your prescribed medications.