[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283896-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283896-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-prescription-drug-coverage-determination-coverage-determination-request","REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION - Coverage Determination Request","","Request form for Medicare prescription drug coverage decisions, collecting enrollee and requestor identity details, representative authorization, and the requested prescription drug information. The form supports multiple coverage determination types, including formulary and tiering exceptions, prior authorization, quantity limits, copayment tier differences, reimbursement for out-of-pocket payments, and related requirements. It also includes instructions for expedited decisions when waiting 72 hours could harm life or health, plus supporting information for the exception/prior authorization request with prescriber and medical data.",{"@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-request/283896/",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-request/283896.png","ImageObject",442,249,{"name":42,"@type":43},"Finn","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is allowed to make a coverage determination request on behalf of the enrollee?","Question",{"text":63,"@type":64},"The prescriber may request on the enrollee’s behalf. If another person (such as a family member or friend) requests, that person must be the enrollee’s representative, and documentation for authorization is required.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What types of coverage determination requests can be made on this form?",{"text":68,"@type":64},"The form supports formulary exceptions, prior authorization, exceptions to trying another drug, quantity limits, tiering exceptions, situations where a drug was moved to a higher tier or removed from the formulary list, and reimbursement requests for covered drugs paid out of pocket.",{"name":70,"@type":61,"acceptedAnswer":71},"When can an expedited decision be requested and how is it requested?",{"text":72,"@type":64},"An expedited (fast) decision can be requested when waiting 72 hours could seriously jeopardize life or health or the enrollee’s ability to regain maximum function. Checking the expedited review box and obtaining the prescriber’s supporting statement are required, and the decision may be 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},283896,1790052547,{"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":33,"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},34359740700684,"https://ap-avatar.wpscdn.com/avatar/1f400023980c374ae676?_k=1777273430885731487","57505  \n REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION   \nThis form may be sent to us by mail or fax:  \nAddress:  Fax Number:  \nExpress Scripts 1.877.328.9799  \nAttn: Medicare Reviews  \nP.O. Box 66571  \nSt. Louis , MO 63166-6571  \nYou may also ask us for a coverage determination by phone at 1.800.935.6103 or through our website [at](at www.Express-Scripts.com)[ www.Express-Scripts.com](at www.Express-Scripts.com).  \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 or prescriber:  \n\n| Requestor’s Name |  |  |\n| --- | --- | --- |\n| Requestor’s Relationship to Enrollee |  |  |\n| Address |  |  |\n| City | State | Zip Code |\n| Phone |  |  |\n\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  \n.  \nName of prescription drug you are requesting (if known, include strength and quantity requested per month):  \nrepresentative, contact your plan or 1-800-Medicare  \n57505  \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) .*  \n 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 copayment (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 anyother 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\nImportant Note: Expedited Decisions  \nIf you or your prescriber believes 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 prescribers support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are as","cbCaibXt1NU6z0Aa","https://ap.wps.com/l/cbCaibXt1NU6z0Aa","pdf",154197,"English","# Enrollee information\n## Requestor and representation information\n## Requested prescription drug details\n# Type of coverage determination request\n## Expedited decisions\n# Signature and dates\n# Supporting information for exception or prior authorization\n## Prescriber information\n## Diagnosis and medical information\n## Rationale for request","[{\"question\":\"Who is allowed to make a coverage determination request on behalf of the enrollee?\",\"answer\":\"The prescriber may request on the enrollee’s behalf. If another person (such as a family member or friend) requests, that person must be the enrollee’s representative, and documentation for authorization is required.\"},{\"question\":\"What types of coverage determination requests can be made on this form?\",\"answer\":\"The form supports formulary exceptions, prior authorization, exceptions to trying another drug, quantity limits, tiering exceptions, situations where a drug was moved to a higher tier or removed from the formulary list, and reimbursement requests for covered drugs paid out of pocket.\"},{\"question\":\"When can an expedited decision be requested and how is it requested?\",\"answer\":\"An expedited (fast) decision can be requested when waiting 72 hours could seriously jeopardize life or health or the enrollee’s ability to regain maximum function. Checking the expedited review box and obtaining the prescriber’s supporting statement are required, and the decision may be provided within 24 hours.\"}]","REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION - Coverage Determination Request | PDF",1789621711]