REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION







  • You may also ask us for a coverage determination by phone at (888)978-0862

  • Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.










  • Requestor's Name







    • Representation documentation for requests made by someone other than enrollee or the enrollee's prescriber:
    • Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). This documentation should be attached under the Attachments section of this request form below. For more information on appointing a representative, contact your plan or 1-800-Medicare.
    • Name of prescription drug you are requesting (if known, include strength and quantity requested per month);

Type of Coverage Determination Request









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 and TIERING EXCEPTION requests cannot be processed without a prescriber's supporting statement. PRIOR AUTHORIZATION requests may require supporting information.
  • Name
    Practice Name












    • Attachments are optional. If needed you can upload and attach files to this request.
      The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .xlsx, .ppt, .txt"
      Files must be 3 MB (3,000,000 bytes) or less.

    •  
  • Diagnosis and Medical Information










  • (if the condition being treated with the requested drug is symptom e.g. anorexia,weight loss,shortness of breath,chest pain,nausea,etc., provide the diagnosis causing the symptom(s) if known)



  • Drug History: (for treatment of the condition(s) requiring the requested drug)





  • DRUG SAFETY

  • HIGH RISK MANAGEMENT OF DRUGS IN THE ELDERLY

  • OPIOIDS-(please complete the following questions if the requested drug is an opioid)

  • mg/day



  • Rationale for Request

  • First Choice VIP Care Plus is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits for both programs to enrollees.
  • H8213_001_FRM_709581_Accepted_10312019