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Collects enrollee identifying information and allows a prescriber or designated representative to submit on the enrollee’s behalf, including required authorization documentation. Requests specify the type of coverage decision such as formulary or tiering exceptions, prior authorization, quantity limits, or reimbursement for out-of-pocket payments. 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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) :  \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 determination if you are asking us to pay you back for a drug you already received.  \n☐CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITH","cbCaimBy3eYb9GwN","https://ap.wps.com/l/cbCaimBy3eYb9GwN","pdf",125108,"English","# Who May Make a Request\n# Enrollee’s Information\n# Requestor/Prescriber Information and Representation Documentation\n# Type of Coverage Determination Request\n# Expedited (Fast) Decision\n# Signature and Date\n# Supporting Information for an Exception Request or Prior Authorization\n## Drug and Therapy Details\n## Diagnosis and ICD-10 Codes\n## Drugs Tried and Results","[{\"question\":\"Who is allowed to make a request for a coverage determination?\",\"answer\":\"The enrollee’s prescriber may request on the enrollee’s behalf. If another individual makes the request, that person must be the enrollee’s representative.\"},{\"question\":\"What types of coverage determination requests can be made on this form?\",\"answer\":\"The form supports formulary exception requests, prior authorization requests, exceptions to trial-before-coverage requirements, quantity limit exceptions, tiering exceptions, and reimbursement for covered prescriptions paid out of pocket.\"},{\"question\":\"How does an expedited decision request work?\",\"answer\":\"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 can be requested. A supporting statement from the prescriber is required for the 24-hour decision option.\"}]","REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION | PDF",1789632317]