Coverage Determination


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

9250 West Flagler Street Suite 600
Miami, FL 33174-3460
Fax Number:

You may also ask us for a coverage determination by phone at 1-833-272-9773 or through our website at .

"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.

Enrollment Information

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

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's Information

Diagnosis and Medical Information

ICD-10 Code(s)

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)
DATES of Drug Tried
RESULTS of previous drug tried FAILURE vs INTOLERANCE (explain)


Any FDA NOTED CONTRAINDICATIONS to the requested Drug    
Any concern for a DRUG INTERACTION with the addition of the requested drug to the Enrollee's current drug regimen?    
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.


If the Enrollee is over the age of 65, do you feel that the benefits of treatment with the requested drug outweigh the potential risks in this elderly patient?    

OPIOIDS- (Please complete the following questions if the requested drug is an opioid)

What is the daily cumulative Morphine Equivalent Dose (MED)?
Are you aware of other Opioid prescribers for the enrollee?    
If so, Please explain
Is the stated daily MED dose noted medically necessary?    
Would a lower daily MED dose be insufficient to control the enrollee's plan?    


Required Rationale Explanation