Prescription drug coverage determination request

Please use this form to request a Medicare prescription drug coverage determination. You may also ask us for a coverage determination by phone at 1-888-786-7509.

Please correct the items below.

1. Enrollee's information

Please enter an enrollee's member ID #.
Please enter an enrollee's first name.
Please enter a middle initial.
Please enter a last name.
Date of birth month is required.
Please enter a day.
Please enter a year.

Date of birth

Please enter height (feet).
Please enter inches.
Please enter weight (lbs).
Please enter a street address.
Please enter a city.
Please select a state.
Please enter a ZIP.
Please enter a telephone number.

Please tell us who you are:

This information is required.

* The enrollee's prescriber may ask Moda Health for a coverage determination on his/her behalf.

** If the enrollee would like another individual (such as a family member or friend) to make a request for on his/her behalf, that individual must be the enrollee's authorized representative. Please contact us to learn how to designate an authorized representative.

Authorized representative's information

You have indicated that you are not the enrollee or prescriber. Please complete the following information:

Please enter a representative's first name.
Please enter a middle initial.
Please enter a last name.
Please enter relationship to enrollee.
Please enter a street address.
Please enter a city.
State is required.
Please enter a ZIP.
Please enter a telephone number.

Upload authorized representative form

Please attach documentation establishing your authority to represent the enrollee (a complete authorization form CMS-1696 or a written equivalent).

For more information on appointing a representative, please contact Moda Health or call 1-800-MEDICARE.

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2. Prescription drug request

Please enter your requested medication below:

Please enter medication name.
Please enter strength.
Please enter route of medication administration.
Please enter frequency.
Please enter quantity.
Please enter diagnosis.
This information is required.

Is this a new prescription?

Month is required
Please enter a day.
Please enter a year.
Please enter expected length of therapy.
Please enter drug allergies.

3. Prescriber's information

Please enter a prescriber's first name.
Please enter a last name.
Please enter a street address.
Please enter a city.
Please select a state.
Please enter a ZIP.
Please enter office telephone.
Please enter office fax.

Please sign and date below

Please enter a prescriber's signature.

4.

Please select all of the statements that apply to this request:

Please select one or more of the statements below.

* Please note: If you are asking for a formulary or tiering exception, your prescriber must provide a statement supporting your request.

Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information.

Your prescriber may use the attached "Supporting Information for an Exception Request or Prior Authorization" to support your request.

5.

Please select one or more of the statements below.

Since the above is checked please choose one of the below fields
Since the above is checked this field is required
Since the above is checked this field is required
Since the above is checked this field is required
Since the above is checked this field is required
Since the above is checked please choose one of the below fields

Since the above is checked these fields are required
Since the above is checked these fields are required
Since the above is checked this field is required

6.

Do you have supporting documentation?

This information is required.

Upload supporting documentation

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7.

Do you need a decision in 24 hours?

This information is required.

If the enrollee, prescriber, or authorized representative believes that waiting 72 hours for a standard decision could seriously harm the life, health, or ability of the enrollee to regain maximum function, an expedited (fast) decision can be requested.

If the prescriber indicates that waiting 72 hours could seriously harm the enrollee's health, Moda Health will provide a decision within 24 hours.

If the enrollee or authorized representative does not obtain the prescriber's support for an expedited request, Moda Health will decide if the case requires a fast decision.

The enrollee or authorized representative cannot request an expedited coverage determination if he/she is asking Moda Health to refund costs for a drug that has already been sent.

8. Confirm your request

  • Enrollee:
  • Medication name:
  • Strength/dosage:
  • Quantity:
  • Prescriber:
  • Rationale for request:
  • Request for expedited decision:

Please sign and date below

Please enter name.
This field is required
Please enter a day.
Please enter a year.