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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)







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.

Website Last Updated: 3/1/2017
Y0041_HM_17_43499g Approved 3/31/2017