Tip for CMS model coverage determination form

Your prescriber should call the plan's coverage determination line to request an expedited decision if urgent

Tip for CMS model coverage determination form

Ask about the plan's exceptions process for drugs not on the formulary or on a higher tier

Tip for CMS model coverage determination form

If you are currently taking a medication that the plan does not cover, you may have a transition fill available for the first 90 days of enrollment

MedicarehardDoctor signature required

Part D Coverage Determination Request

CMS model coverage determination form · CMS

Request for Part D coverage determination including formulary exception, tiering exception, or waiver of utilization management such as step therapy or quantity limits.

Form Details

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Where to Submit This Form

📬

Mail to your Part D plan's coverage determination department

Address is on your plan membership materials or denial notice.

📠

Fax to your Part D plan

Fax number is on your plan's formulary or membership card.

🌐

Through your plan's member portal (if available)

Some Part D plans accept electronic requests.

Filing Deadline

No specific deadline for initial requests, but submit promptly for timely access to medications.

Required Attachments

📎 Prescriber's supporting statement explaining medical necessity
📎 Documentation of prior medications tried and failed (for step therapy exceptions)
📎 Relevant diagnosis and treatment history
📎 Prescription details (drug name, dose, quantity, days supply)

Processing Time

Standard: 72 hours. Expedited: 24 hours if delay could seriously jeopardize health, life, or ability to regain maximum function.

What Happens Next

The plan will approve, deny, or provide an alternative. If denied, you receive a written notice with appeal rights. Your prescriber can request an expedited determination.

Tips for This Form

✓ Your prescriber should call the plan's coverage determination line to request an expedited decision if urgent
✓ Ask about the plan's exceptions process for drugs not on the formulary or on a higher tier
✓ If you are currently taking a medication that the plan does not cover, you may have a transition fill available for the first 90 days of enrollment
✓ Keep records of all medications tried and why they were discontinued

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