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.

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: