Prescription Drug Coverage Determination Form

If you're looking for us to cover a drug that's not currently on our list, you should request a coverage determination.

* = Required

Why are you making this request?
Do you need an expedited decision?
  • Yes, I need an expedited decision.
If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm you, you can ask for an expedited decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we’ll give you a decision within 24 hours. If you don’t get your prescriber’s support for an expedited request, we’ll decide if your case requires a fast decision. You can’t request an expedited decision if you’re asking us to pay you back for a drug you already received.
  • Acknowledgment with legal language goes here

Please complete this section only if you are filling out this form for someone else and you aren't the prescribing doctor.

Type the above number: