Skip to main content

Request for Medicare prescription drug coverage determination

Member’s information

 

Please provide the following information. All fields marked with an asterisk (*) are required.

Example: 12345
Example: 1234567890
Name of prescription drug you are requesting. If known, include strength and quantity requested per month.
*Are you filing this request on behalf of someone else?

Type of coverage determination request

 

Please provide details of the coverage determination request below. All fields marked with an asterisk (*) are required.

*Check the boxes that apply

NOTE: If you are asking for a formulary 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 steps 3, 4 and 5 of this form to support your request.

Please add any additional information we should consider.

 

If you have supporting documents, you can fax them to us at 1-844-814-2260 or mail them to us at Aetna Assure Premier Plus (HMO D-SNP), Attn: Part D Coverage Determination, Pharmacy Department, 4750 S. 44 Place, Suite 150 Phoenix, AZ 85040.

Important note: Expedited decisions

 

If 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.

Supporting information for an exception request or prior authorization

 

Formulary exception requests cannot be processed without a prescriber’s supporting statement. Prior authorization requests may require supporting information.

Please provide details of the coverage determination request below. 

 

Prescriber’s information

Example: 12345
Example: 1234567890
Example: 1234567890

Diagnosis and medical information

 

Please provide details of the coverage determination request below.

Medication strength and route of administration
New prescription date or date therapy initiated
Expected length of therapy (if known)

Rationale for request

Check the boxes that apply
Today's date

Also of interest: