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Enables an enrollee, their representative, or their prescriber to submit formulary exception, prior authorization, quantity limit, tiering exception, reimbursement, and expedited decision requests. Collects enrollee and requestor details, drug name and requested details, supporting documentation requirements, and prescriber representation documentation when someone other than the enrollee makes the request. 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Another individual (family member or friend) may request only if they are named as the enrollee’s representative.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What are formulary exceptions and when do you need prescriber support?",{"text":113,"@type":109},"Formulary and tiering exception requests cannot be processed without a prescriber’s supporting statement. Requests may also require supporting information for prior authorization or other utilization management requirements.",{"name":115,"@type":106,"acceptedAnswer":116},"When can an expedited (fast) coverage decision be requested?",{"text":117,"@type":109},"An expedited decision can be requested if waiting 72 hours for a standard decision could seriously harm the enrollee’s life, health, or ability to regain maximum function. 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Box 52000 MC109  \nPhoenix, AZ 85072-2000  \nYou may also ask us for a coverage determination by phone at 1-866-986-0356 (TTY: 711), Sunday-Saturday, 8am-8pm or through [our website at www.metroplusmedicare.org](our website at www.metroplusmedicare.org).  \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):  \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 coverage determ","cbCaimuzJHtL2CGU","https://ap.wps.com/l/cbCaimuzJHtL2CGU","pdf",270377,"English","# Enrollee and requestor information\n## Request type selection\n## Expedited decisions and documentation\n# Supporting information for exception or prior authorization\n## Prescriber information\n## Diagnosis and medical information\n## Drug history and prior drug trials","[{\"question\":\"Who is allowed to make a coverage determination request?\",\"answer\":\"The prescriber may request on the enrollee’s behalf. Another individual (family member or friend) may request only if they are named as the enrollee’s representative.\"},{\"question\":\"What are formulary exceptions and when do you need prescriber support?\",\"answer\":\"Formulary and tiering exception requests cannot be processed without a prescriber’s supporting statement. Requests may also require supporting information for prior authorization or other utilization management requirements.\"},{\"question\":\"When can an expedited (fast) coverage decision be requested?\",\"answer\":\"An expedited decision can be requested if waiting 72 hours for a standard decision could seriously harm the enrollee’s life, health, or ability to regain maximum function. A fast decision is generally provided within 24 hours when the prescriber indicates it could seriously harm health.\"}]","REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION - Form | PDF",1789632951]