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Covers expedited decision criteria, signature and dates, and requires prescriber supporting statements plus diagnosis, ICD-10 codes, medication history, and drug trial documentation when applicable.",{"@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-prescription-drug-coverage-determination-coverage-determination-form/283967/",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-prescription-drug-coverage-determination-coverage-determination-form/283967.png","ImageObject",442,249,{"name":42,"@type":43},"Stanley","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-28","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is allowed to make a request for coverage determination?","Question",{"text":63,"@type":64},"The enrollee’s prescriber may request on the enrollee’s behalf. Another individual may request only if they are named as the enrollee’s representative and representation documentation is provided.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What are the common types of coverage determination requests on the form?",{"text":68,"@type":64},"Options include formulary exceptions, prior authorization, exceptions to try-another-drug requirements, quantity limit exceptions, tiering exceptions, and requests for reimbursement for a covered drug paid out of pocket.",{"name":70,"@type":61,"acceptedAnswer":71},"When can an expedited (fast) decision be requested?",{"text":72,"@type":64},"An expedited decision can be requested when waiting 72 hours for a standard decision could seriously harm the enrollee’s life or health or ability to regain maximum function. A supporting statement from the prescriber is required to support the expedited request.","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},283967,1790025992,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":92,"language":93,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":94,"faqs":95,"seo_title":96,"seo_description":12,"update_tm":97,"read_time":26},2336477405376,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0",17,"REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION  \nThis form may be sent to us by mail or fax:  \nAddress: Fax Number:  \nHumana Clinical Pharmacy Review (HCPR) 1-877-486-2621  \nP.O. Box 14601 Lexington, KY 40512  \nYou may also ask us for a coverage determination by phone at 1-800-555-2546 or through our website [at www.humana.com/provider/pharmacy-resources/prior-authorizations](at www.humana.com/provider/pharmacy-resources/prior-authorizations).  \nWho May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.  \nEnrollee’s Information  \n\n| Enrollee’s Name |  | Date of Birth |\n| --- | --- | --- |\n| Enrollee’s Address |  |  |\n| City | State | Zip Code |\n| Phone | Enrollee’s Member ID \\# |  |\n\nComplete the following section ONLY if the person making this request is not the enrollee  \n\n| Requestor’s Name |  |  |\n| --- | --- | --- |\n| Requestor’s Relationship to Enrollee |  |  |\n| Address |  |  |\n| City | State | Zip Code |\n| Phone |  |  |\n\nor prescriber:  \nRepresentation documentation for requests made by someone other than enrollee or the  \nenrollee’s prescriber:  \nAttach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) . For more information on appointing a representative, contact your plan or 1-800-Medicare.  \nName of prescription drug you are requesting (if known, include strength and quantity requested per month):  \nType of Coverage Determination Request  \n☐I need a drug that is not on the plan’s list of covered drugs (formulary exception) . *  \n☐I have been using a drug that was previously included on the plan’s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception) . *☐I request prior authorization for the drug my prescriber has prescribed.*  \n☐I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception) .*  \n☐I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception) .*  \n☐My drug plan charges a higher copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower  \ncopayment (tiering exception) . *  \n☐I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception) . *  \n☐My drug plan charged me a higher copayment for a drug than it should have.  \n☐I want to be reimbursed for a covered prescription drug that I paid for out of pocket.  \n*NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached “Supporting Information for an Exception Request or Prior Authorization” to support your request.  \nAdditional information we should consider (attach any supporting documents) :  \n\n|  |\n| --- |\n|  |\n|  |\n\nImportant Note: Expedited Decisions  \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 will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request , we will decide if your case requires a fast decision. You cannot request an expedited coverag","cbCaij0NkBBfALgL","https://ap.wps.com/l/cbCaij0NkBBfALgL","pdf",265147,5,"English","# Enrollee and Requestor Information\n## Enrollee’s information\n## Requestor information and representation documentation\n# Prescription Drug and Request Type\n## Name, strength, and quantity requested\n## Coverage determination request options\n# Expedited Decisions and Certification\n## 24-hour expedited review criteria\n# Supporting Information and Medical Details\n## Prescriber supporting statement requirements\n## Diagnosis, ICD-10 codes, and drug history\n## Drugs tried and results","[{\"question\":\"Who is allowed to make a request for coverage determination?\",\"answer\":\"The enrollee’s prescriber may request on the enrollee’s behalf. 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