REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
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1 REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Kaiser Permanente Attention: Medicare Part D Review P.O. Box Oakland, CA You may also ask us for a coverage determination by phone at or through our website at kp.org. 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 to learn how to name a representative. Enrollee s Information Enrollee s Name Date of Birth Enrollee s Address City State Zip Code Phone Enrollee s Member ID # Complete the following section ONLY if the person making this request is not the enrollee or prescriber: Requestor s Name Requestor s Relationship to Enrollee Address City State Zip Code Phone Representation documentation for requests made by someone other than enrollee or the enrollee s prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or Medicare. Name of prescription drug you are requesting (if known, include strength and quantity requested per month): Y0043_N CMS Approved (12/12/2011)
2 Type of Coverage Determination Request I need a drug that is not on the plan s list of covered drugs (formulary exception).* I have been using a drug that was previously included on the plan s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).* I request prior authorization for the drug my prescriber has prescribed.* I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception).* 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 have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).* My drug plan charged me a higher copayment for a drug than it should have. I want to be reimbursed for a covered prescription drug that I paid for out of pocket. *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 use the attached Supporting Information for an Exception Request or Prior Authorization to support your request. Additional information we should consider (attach any supporting documents): Important Note: 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 (if you have a supporting statement from your prescriber, attach it to this request). Signature of person requesting the coverage determination (the enrollee, or the enrollee s prescriber or representative): Y0043_N CMS Approved (12/12/2011) Date:
3 Supporting Information for an Exception Request or Prior Authorization FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber s supporting statement. PRIOR AUTHORIZATION requests may require supporting information. REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify that applying the 72 hour standard review timeframe may seriously jeopardize the life or health of the enrollee or the enrollee s ability to regain maximum function. Prescriber's Information Name Address City State Zip Code Office Phone Fax Prescriber s Signature Date Diagnosis and Medical Information Medication: Strength and Route of Administration: Frequency: New Prescription OR Date Therapy Initiated: Expected Length of Therapy: Quantity: Height/Weight: Drug Allergies: Diagnosis: Rationale for Request Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure [Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)] Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change [Specify below: Anticipated significant adverse clinical outcome] Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason] Request for formulary tier exception [Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome] Other (explain below) Required Explanation: Y0043_N CMS Approved (12/12/2011)
4 Notice of nondiscrimination Kaiser Foundation Health Plan, Inc. (KFHP) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. KFHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats, such as large print, audio, and accessible electronic formats. Provide no cost language services to people whose primary language is not English, such as: Qualified interpreters. Information written in other languages. If you need these services, call Member Services at (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that KFHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at In California, Kaiser Permanente is an HMO plan and a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. H0524_H6050_H6052_1557nondis accepted
5 Multi-language Interpreter Services English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Armenian ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください H0524_H6050_H6052_17MLI accepted CA
6 Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). Farsi توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی باشد. با (711 (TTY: تماس بگیرید. بصورت رایگان برای شما فراھم می Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان (رقم ھاتف الصم والبكم: -117). اتصل برقم
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