[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283924-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283924-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","request-for-medicare-drug-coverage-determination-use-the-form-to-request-a-coverage-determination","Request for Medicare Drug Coverage Determination - Use the form to request a coverage determination","","Request for Medicare Drug Coverage Determination form used to ask a plan for a coverage decision for prescribed or covered drugs. Collects enrollee and requestor identity details, specifies the drug and type of request (reimbursement, prior authorization, formulary/quantity/tiering exceptions, or other coverage-related issues), and allows an expedited decision request when a 72-hour review may seriously jeopardize health. Includes prescriber sections for supporting statements, medication and diagnosis details with ICD-10 codes, drug history, safety questions, and high-risk elderly management.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/request-for-medicare-drug-coverage-determination-use-the-form-to-request-a-coverage-determination/283924/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/request-for-medicare-drug-coverage-determination-use-the-form-to-request-a-coverage-determination/283924.png","ImageObject",442,249,{"name":42,"@type":43},"wps_ap_test_251126_0180","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",8,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who can submit a request for a Medicare drug coverage determination, and what details are required?","Question",{"text":63,"@type":64},"The request can be made by the plan enrollee, a doctor/prescriber, or an authorized representative. The form collects identity details including name, date of birth, address, phone, and member ID, plus requestor relationship and authority documentation when applicable.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What types of coverage determinations can this form request?",{"text":68,"@type":64},"It covers scenarios such as reimbursement for a covered drug already paid out of pocket, prior authorization, formulary exceptions, quantity (pill limit) exceptions, exceptions to prior authorization rules, and tiering exceptions for copayment differences or tier changes.",{"name":70,"@type":61,"acceptedAnswer":71},"When can an expedited (fast) decision be requested, and what happens if the request is supported?",{"text":72,"@type":64},"If waiting 72 hours for a standard decision could seriously harm life, health, or the ability to regain maximum function, an expedited request can be submitted. When the prescriber indicates serious harm, a decision is automatically provided within 24 hours.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283924,1790455218,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":121,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},8796095027276,"https://avatar.qwps.com/avatar/d3BzX2FwX3Rlc3RfMjUxMTI2XzAxODA=","REQUEST FOR MEDICARE DRUG COVERAGE DETERMINATION  \nUse this form to ask our plan for a coverage determination. You can also ask for a coverage determination by phone at 1-877-813-5595 or through [our website at](our website at express-scripts.com. You)[ express-scripts.com](our website at express-scripts.com. You)[. You](our website at express-scripts.com. You), your doctor or prescriber, or your authorized representative can make this request.  \nPlan Enrollee  \n\n| Name | Date of birth |\n| --- | --- |\n| Street address | City |\n| State | ZIP |\n| Phone | Member ID \\# |\n\nIf the person making this request isn’t the plan enrollee or prescriber:  \n\n| Requestor’s name |  |\n| --- | --- |\n| Relationship to plan enrollee |  |\n| Street address (include City, State and ZIP |  |\n| Phone |  |\n| 􀂅 | Submit documentation with this form showing your authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or equivalent) . For more information on appointing a representative, contact our plan or call 1-800-MEDICARE. (1- 800-633-4227) . TTY users can call 1-877-486-2048. |\n\nName of drug this request is about (include dosage and quantity information if available)  \nINT_25_ 1587753892_C  \nType of Request  \n☐ My drug plan charged me a higher copayment for a drug than it should have ☐ I want to be reimbursed for a covered drug I already paid for out of pocket  \n☐ I’m asking for prior authorization for a prescribed drug (this request may require supporting information)  \nFor the types of requests listed below, your prescriber MUST provide a statement supporting the request. Your prescriber can complete pages 3 and 4 of this form,“Supporting Information for an Exception Request or Prior Authorization.”  \n☐I need a drug that’s not on the plan’s list of covered drugs (formulary exception)  \n☐ I’ve been using a drug that was on the plan’s list of covered drugs before, but has been or will be removed during the plan year (formulary exception)  \n☐ I’m asking for an exception to the requirement that I try another drug before I get a prescribed drug (formulary exception)  \n☐ I’m asking for an exception to the plan’s limit on the number of pills (quantity limit) I can get so that I can get the number of pills prescribed to me (formulary exception)  \n☐ I’m asking for an exception to the plan’s prior authorization rules that must be met before I get a prescribed drug (formulary exception) .  \n☐ My drug plan charges a higher copayment for a prescribed drug than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception)  \n☐ I’ve been using a drug that was on a lower copayment tier before, but has or will be moved to a higher copayment tier (tiering exception)  \nAdditional information we should consider (submit any supporting documents with this form):  \nDo you need an expedited decision?  \nIf you or your 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. If your prescriber indicates that waiting 72 hours could seriously harm your health, we’ll automatically give you a decision within 24 hours. If you don’t get your prescriber's support for an expedited request, we’ll decide if your case requires a fast decision. (You can’t ask for an expedited decision if you’re asking us to pay you back for a drug you already received. )  \n☐ YES, I need a decision within 24 hours. If you have a supporting statement from your prescriber, attach it to this request.  \n\n| Signature: | Date: |\n| --- | --- |\n\nHow to submit this form  \nSubmit this form and any supporting information by mail or fax:  \nAddress:  \nExpress Scripts  \nAttn: Medicare Reviews P.O. Box 66571  \nSt. Louis, MO 63166-6571  \nFax Number:  \n1-866-845-7267  \nSupporting Information for an Exception Request or Prior Authorization  \nTo be completed by the prescriber  \n☐ REQUEST FOR EXPEDITED REVIE","cbCaij8PYgTJxEoC","https://ap.wps.com/l/cbCaij8PYgTJxEoC","pdf",977559,"English","# Plan Enrollee Information\n# Requestor Information (if not enrollee or prescriber)\n# Drug and Type of Request\n# Expedited Decision Request\n# Enrollee Signature\n# How to Submit the Form\n# Supporting Information for an Exception Request or Prior Authorization\n## Prescriber Information\n## Diagnosis and Medical Information\n## Drug History and Current Regimen\n## Drug Safety and Interaction Questions\n## High-Risk Management of Drugs in the Elderly","[{\"question\":\"Who can submit a request for a Medicare drug coverage determination, and what details are required?\",\"answer\":\"The request can be made by the plan enrollee, a doctor/prescriber, or an authorized representative. The form collects identity details including name, date of birth, address, phone, and member ID, plus requestor relationship and authority documentation when applicable.\"},{\"question\":\"What types of coverage determinations can this form request?\",\"answer\":\"It covers scenarios such as reimbursement for a covered drug already paid out of pocket, prior authorization, formulary exceptions, quantity (pill limit) exceptions, exceptions to prior authorization rules, and tiering exceptions for copayment differences or tier changes.\"},{\"question\":\"When can an expedited (fast) decision be requested, and what happens if the request is supported?\",\"answer\":\"If waiting 72 hours for a standard decision could seriously harm life, health, or the ability to regain maximum function, an expedited request can be submitted. When the prescriber indicates serious harm, a decision is automatically provided within 24 hours.\"}]","Request for Medicare Drug Coverage Determination - Use the form to request a coverage determination | PDF",1789622539]