REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
This form may be sent to us by mail or fax:
9250 West Flagler Street Suite 600
Miami, FL 33174-3460
You may also ask us for a coverage determination by phone at 1-833-272-9773 or through our website at https://www.youroptimumhealthcare.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.
Type of Coverage Determination Request
*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.
Important Note: Expedited Decisions
Supporting Information for an Exception Request or Prior Authorization
Diagnosis and Medical Information
Other RELAVENT DIAGNOSES:
DRUG HISTORY: (for treatment of the condition(s) requiring the requested drug)
(if quantity limit is an issue, list unit dose/total daily dose tried)
RESULTS of previous drug tried FAILURE vs INTOLERANCE (explain)
If the answer to the either of the questions noted above is yes, please (1) explain issue, (2) discuss the benefits vs potential risks despite the noted concern, and (3) monitoring plan to ensure safety.
HIGH RISK MANAGEMENT OF DRUGS IN THE ELDERLY
OPIOIDS- (Please complete the following questions if the requested drug is an opioid)
Required Rationale Explanation