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.



Y0001_M_OT_WB_30779 CMS Approved 

Page Last Updated: November 30, 2015