Coverage Determination Form

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 at 800-331-6293 to learn how to name a representative.

Members and/or Representatives: Complete Section 1 Only

Prescribers: Complete Sections 1 and 2

Section 1
Customer ID: *
Patient First Name: *
Patient Last Name: *
Patient Date of Birth: *
Patient Phone: *
Patient Address: *
Medication Name: *
Physician First Name: *
Physician Last Name: *
Comments/Supporting Information:
Section 2
Physician Information
Physician NPI: *
Physician Specialty: *
Contact Name: *
Physician Phone: *
Physician Fax: *  
Physician Address: *
Medication Information
Dosage: *
Quantity: *
Frequency: *
Diagnosis Information
Prescribing Diagnosis: *
Diagnosis Code(s): *
Date Therapy Initiated: *
Clinical Criteria
Please provide rationale supporting your request for Coverage Determination.
  • If request is for a non-preferred medication, please provide clinical documentation supporting:
    Name of preferred therapy, dates and duration of alternate therapy tired and response to therapy.
Clinical Criteria: *
*Failure to provide clinical documentation supporting rationale may result in this request being denied.*
Note: Scanned or other electronic documents cannot be uploaded or attached. If you have additional supporting documents, you will need to mail or fax them separately to the number or address below.