Prescription Drug Coverage Decision Form

Member’s information

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

*Name

*Date of birth

*Address 1

Address 2

*City

*State

Zip Code Example: 12345

*Phone Number Example: 1234567890

*Member ID

*Drug requested

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?

Yes, I am an appointed representative

No, I am the member

Please provide documentation showing the authority to represent the member (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted previously. You can mail, fax or email the documentation directly to us. You can find all our contact information on our “Contact us” page.

Your information

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

*Name

*Relationship Your relationship to member

*Address 1

Address 2

*City

*State

Zip Code Example: 12345

*Phone Number Example: 1234567890

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

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).

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 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.

More information

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.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS. If you have a supporting statement from your prescriber, you can fax it to us at 1-844-814-2260 or mail it to us at Aetna Assure Premier Plus (HMO D-SNP), Attn: Part D Appeals, Pharmacy Department, PO Box 818001 Cleveland, OH 44181-8001

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.

REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify that applying the 72-hour standard review time frame may seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.

Please provide details of the coverage determination request below.

Prescriber’s information

Name

Address 1

Address 2

City

State

Zip Code Example: 12345

Office Phone Example: 1234567890

fax Example: 1234567890

Diagnosis and medical information

Please provide details of the coverage determination request below.

Medication

Strength and route Medication strength and route of administration

Frequency

New prescription date New prescription date or date therapy initiated

length of therapy Expected length of therapy (if known)

quantity

Height/weight

Drug allergies

diagnosis

Rationale for request

Check the boxes that apply

Alternate drugs are contraindicated or were previously tried, but with an adverse outcome, such as toxicity, allergy or therapeutic failure. Specify below: (1) drugs contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, the length of therapy on each drug.

Patient is stable on their current drug, and there is a high risk of a significant adverse clinical outcome with a medication change. Specify below: anticipated significant adverse clinical outcome.

There is a medical need for a different dosage form or a higher dosage. Specify below: (1) dosage forms and dosages tried; (2) explanation of medical reason.

There is another reason for this request. Explain below.

Required explanation

*Signature

*Date Today's date

*Signature Type

What's covered?

For members

Request for Medicare prescription drug coverage determination

Member’s information

Your information

Type of coverage determination request

Important note: Expedited decisions

Supporting information for an exception request or prior authorization

Diagnosis and medical information

Rationale for request

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