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Request for Medicare Prescription Drug Coverage Determination

Please submit this form to make a request for Medicare prescription drug coverage determination.

You may also request coverage determination by calling 1-888-678-7015 (TTY/TDD: 711).

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. Please call us to learn how to name a representative.

Member's information (* Required Fields)


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Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor's information












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I need a drug that is not on the plan's list of covered drugs.

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.

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.

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.

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.

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.

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.


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.

REQUEST FOR EXPEDITED REVIEW: 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.

I need a decision within 24 hours.

Prescriber's information


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Diagnosis and medical information












Rationale for request (to be completed by prescriber)


Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure (Specify in explanation field: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s))

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change (Specify in explanation field: Anticipated significant adverse clinical outcome)

Medical need for different dosage form and/or higher dosage (Specify in explanation field: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason)

Request for formulary tier exception (Specify in explanation field: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome)

Other (Specify in explanation field)







Independence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Independence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. View our documentation for more information and to request language assistance services.

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To ensure your privacy, all information will be sent via a secure connection. Independence Blue Cross will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law. Please see our Notice of Privacy Practices for more information.

To file an appeal or grievance for your medical benefit coverage or your prescription drug coverage, contact Keystone 65 Customer Service at 1-800-645-3965 or Personal Choice 65 Customer Service at 1-888-718-3333; TTY/TDD users should call 711, 7 days a week, 8 a.m. to 8 p.m.; or you can complete and submit online the Request for Medicare Prescription Drug Coverage Determination or the Request for Redetermination of Medicare Prescription Drug Denial.

For additional information from the Centers for Medicare and Medicaid Services (CMS) visit http://www.medicare.gov. If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form. For additional assistance, visit The Office of the Medicare Ombudsman.

Independence Blue Cross offers Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal.

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

You must continue to pay your Medicare Part B premium.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, premium and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Medicare beneficiaries may also enroll in Keystone 65 HMO, Personal Choice 65SM PPO, or Select Option® PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Keystone 65 HMO and Personal Choice 65SM PPO: For accommodation of persons with special needs at sales meetings call toll-free 1-877-393-6733 (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. A sales person will be present with information and applications.

Select Option® PDP: For accommodation of persons with special needs at sales meetings call toll-free 1-888-678-7009 (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. A sales person will be present with information and applications.

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

MedigapSecurity plans are offered through Independence Blue Cross and Highmark Blue Shield, independent licensees of the Blue Cross and Blue Shield Association. MedigapSecurity is not connected with or endorsed by the U.S. government or the federal Medicare program. To join, you must be enrolled in Medicare Parts A and B. Plan F and Plan N are available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. You must continue to pay Medicare Part A (if applicable) and Part B premiums.

The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. ©2018. All rights reserved.

TruHearing® is a registered trademark of TruHearing, Inc., an independent company.

FutureScripts® is an independent company that provides pharmacy benefit management services.

Out-of-network/non-contracted providers are under no obligation to treat Independence Blue Cross Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Website Last Updated: 10/1/2017
Y0041_HM_18_56568 Approved 10/12/2017