Coverage Determination form

Please complete one form per Medicare Prescription Drug you are requesting a Coverage Determination for.

This form may also be sent to us by mail or fax:

Appeals Department
P.O. Box 52000
Phoenix, AZ 85072-2000

Fax Number: 1-855-633-7673

You may also ask us for a coverage determination by phone 24 hours a day, 7 days a week by calling the telephone number on the back of your Blue MedicareRx id card.

All fields are optional unless marked required.

Enrollee's Information

Who may make a request: 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.

Enter a valid First Name

Enter a valid Last Name

Enter Valid Phone Number

Requestor Information (if not Enrollee - Prescriber, Family Member or Friend)

1Representation 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 Representative Form CMS -1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare. You may also sign and date and fax the Blue MedicareRx (PDP) Appointment of Representative form. Back

Prescription drug you are requesting:

Have you purchased the drug pending appeal?

Type of Coverage Determination

Select all that apply.

2Note: If you are asking for a formulary or tiering exception, your prescribing physician MUST provide a statement to support your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may also use the "Supporting Information for an Exception Request or Prior Authorization" to support your request. Back Back Back Back Back Back

Max characters: 500

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.

Prescriber Information

Diagnosis and Medical Information

Rationale for Request

Select all that apply.

Max characters: 500

Attachments (JPG, PDF, or TIF up to 3 megabytes)

You can submit up to five (5) attachments as supporting documentation. Limit 3 megabytes allowed per prescription drug coverage determination request. If you have other drugs you would like to request a coverage determination request for, please submit a form for each. To save your document into a .jpg or a .tif, go to file, save as, and save it with the extension of your choice. If you are scanning in a document, it is possible your scanner will save it in a .pdf format.

    File Upload Successful.

    File upload Failed. Please Try Again.

    File upload Failed. File size error.

    File upload Failed. Files number error.

    File upload Failed. Invalid File type error.

    Select the checkbox and agree to provide the electronic signature.