Coverage Determination, Exception, Prior Authorization or Appeals for Members - Secure Form

This form may be used by members to initiate a Coverage Determination, Exception or Prior authorization request or initiate Appeal of a denied authorization. This form cannot be used to request drugs excluded by Medicare such as barbiturates, benzodiazepines, fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, over-the-counter drugs or prescription vitamins (except prenatal vitamins and fluoride preparation).

NOTE: This form is sent to the plan through a secure system

* Required

Reason for submitting this form:*

Submit a request for coverage determination, exception or prior authorization of a drug

Submit appeal for denied authorization of a drug

Drug Name* View Full List of Drugs

Member/Enrollee's Information:

First Name*

Last Name*

Date of Birth* MM/DD/YYYY

Member's Medicare Number*

Member's Part D Plan ID Number*

Address

Street Address*

Address Line 2

City*

State*

Zip Code*

Phone*555-555-5555

If you are the member's authorized representative, please provide the following contact information:

Requestor's Name (if not enrollee)

Address

Street Address

Address Line 2

City

State

Zip Code

Phone555-555-5555

Authorized representatives will be required to submit their appointment of representative form.

Prescribing Physician's Information:

Prescribing Physician*

Medical Specialty*

Office Contact Person*

Address

Street Address*

Address Line 2

City*

State*

Zip Code*

Office Phone*555-555-5555

Fax*555-555-5555

Type of Coverage Determination Request:

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 an exception to the requirement that I try another drug before I get the drug my doctor prescribed (formulary exception).*
I request prior authorization for the drug my doctor has 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 doctor prescribed (formulary exception).*
My drug plan charged me a higher copayment for a drug than it should have.
My drug plan charges a higher copayment for the drug my doctor prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).*
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 (tiering 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 or tier exception we will ask your prescribing physician to provide a statement to support your request. Please note that you cannot ask for a tiering exception for a drug in the plan's Specialty Tier (Tier 4) or obtain a brand name drug at the copayment that applies to generic drugs. If you are asking for prior authorization, we will contact your physician to complete the necessary forms to speed up your request. We will provide a response to you once the necessary information is received.

Additional information we should consider:

By entering your name and clicking submit, this will be considered your signature and approval for this request. Your Full Name*

Note that your plan may require additional information. See your plan benefit materials for more information.

Member/Enrollee's Information:

First Name*

Last Name*

Member's Medicare Number*

Member's Part D Plan ID Number*

Address

Street Address*

Address Line 2

City*

State*

Zip Code*

Phone*555-555-5555

Drug Name* View Full List of Drugs

Date of Denied Service* MM/DD/YYYY

Prescribing Physician's Information:

Prescribing Physician*

Medical Specialty

Address

Street Address*

Address Line 2

City*

State*

Zip Code*

Office Phone*555-555-5555

Fax*555-555-5555

If you are the member's authorized representative, please provide the following contact information:

Requestor's Name (if not enrollee)

Address

Street Address

Address Line 2

City

State

Zip Code

Phone555-555-5555

Authorized representatives will be required to submit their appointment of representative form.

By entering your name and clicking submit, this will be considered your signature and approval for this request. Your Full Name*

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Medigap policies offered in Maryland's counties except Prince George's and Montgomery Counties are issued by CareFirst of Maryland, Inc.; Medigap policies offered in Maryland's Prince George's and Montgomery Counties, Washington, D.C. and Virginia are issued by Group Hospitalization and Medical Services, Inc.

Serving Maryland, Delaware, the District of Columbia and portions of Virginia. Medi-CareFirst BlueCross BlueShield is the business name of First Care, Inc. and Group Hospitalization and Medical Services Inc., and each is an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®' Registered trademark of CareFirst of Maryland, Inc.

Medi-CareFirst BlueCross BlueShield is a Medicare-approved Part D sponsor.

Medicare health plans' contract with CMS is renewed annually and the availability of coverage beyond the end of the current contract year is not guaranteed.

S5766_MCFWeb2011 CMS Approved 2/27/2012