Request for Medicare Prescription Drug Coverage Determination

I need a drug that is not on the plan’s list of covered drugs (formulary exception).*

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.*

I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception).*

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).*

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).*

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).*

My drug plan charged me a higher copayment for a drug than it should have.

I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

*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. You could use the additional information section to attach any supporting information for an Exception Request or Prior Authorization to support your request.

Request for Medicare Prescription Drug Coverage Determination

Enrollee’s Information

Exception

Prescriber’s Information

Diagnosis and Medical Information

Signature