Medicare Prescription Drug Coverage Determination Request Form for Enrollees

Medicare Precert
Medicare Precert
If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life or health or ability to regain maximum function, you can ask for an expedited (fast) decision.  If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing, above, or in a telephone call to Member Services at 1-855-249-1282) that he or she agrees that waiting 72 hours could seriously harm your life or health or ability to regain maximum function, we will give you a decision within 24 hours.  If you do not get your physician's support, we will decide if your health condition 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.
Medicare Precert
Medicare Precert

Y0123_3032_10952_NM 10/2017

Page Last Updated: August, 2018

Medicare Precert