Coverage Determination Request Form

Please complete the form below and select Submit to send your request. The information will be sent securely to protect your privacy. Use the web browser print function if you would like to print a copy of this request for your records.

Note: Submitted requests may require a supporting statement from your prescriber.

Download PDF of Coverage Determination Request Form

* Indicates a required field.

Member Information:

Name*

MVP Member ID Number*

Date of Birth (MM/DD/YYYY)*

Address*

City*

State*

Zip*

Phone Number*

Provider Information:

Name*

Address*

City*

State*

Zip*

Phone Number*

Fax Number

NPI Number

DEA Number

Please provide the following information if you are making a request on behalf of the member named above. To make this request, you must be the member’s representative and MVP must have an authorization on file. If we do not have this authorization, please send a completed Authorization of Representation Form CMS-1696 or a written equivalent. For more information on appointing a representative, call the MVP Medicare Customer Care Center or 1-800-MEDICARE.

Requestor Information:

Requestor's Name*

Relationship to Member*

Address*

City*

State*

Zip*

Phone Number*

Prescription Information:

Name of Prescription Drug you are Requesting*

Strength*

Quantity per Month*

Is your doctor aware that you are requesting this prescription?* Yes No

Please choose a reason for your request:

I need a drug that is not on the plan’s list of covered drugs (formulary exception).

I request prior authorization for the drug my prescriber has prescribed.

I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).

My drug plan charges a higher copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).

I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

Please 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 need to submit additional information to support your request.

Additional Information:

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.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS

Note: We may need to contact you for additional information to support your request.