This form may be sent to us by mail or fax:
You may also ask us for a coverage determination by phone at 1-833-272-9772 or through our website at https://www.freedomhealth.com/medicare/pharmacy_and_part_d/ .
"Asterisk mark (*) denotes it is a mandatory field and shouldn't be left blank"
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.
Complete the following section ONLY if the person making this request is not the enrollee or prescriber:
Representation documentation for requests made by someone other than the enrollee or the enrollee's prescriber:
Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent).
For more information on appointing a representative, contact your plan or 1-800-MEDICARE.
*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.
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.
FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber's supporting statement.
PRIOR AUTHORIZATION requests may require supporting information.