Medicare Prescription Drug Coverage Determination Request Form for Enrollees

**NOTE:  If you are asking for a formulary or tiering exception, your PRESCRIBING PHYSICIAN must provide a statement to support your request.  You cannot ask for a tiering exception for a drug in a plan's Specialty Tier.  In addition, you cannot obtain a brand name drug at the copayment that applies to generic drugs.
If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life or health or ability to regain maximum function, you can ask for an expedited (fast) decision.  If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life or health or ability to regain maximum function, we will give you a decision within 24 hours.  If you do not obtain your physician's support, we will decide if your health condition requires a fast decision.

"Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies.  The Aetna companies that offer, underwrite or administer benefit coverage include Aetna Better Health Inc., Aetna Health Inc., Aetna Health of California Inc., Aetna Dental Inc., Aetna Dental of California Inc., Missouri Care, Incorporated, Aetna Health Insurance Company of New York, and Aetna Health Insurance Company and/or Aetna Life Insurance Company.  Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

Y0001_M_OT_WB_30779 CMS Approved 

Page Last Updated: May 1, 2014