Part D Coverage Determination and Appeal Requests

Asking for Prescription Drugs to be Covered

To submit a drug coverage request, you, an authorized representative or provider can submit the request by phone, fax, mail, or online. You can use the forms below to submit requests. Direct requests to the fax number, phone number, or address included on the forms.

Coverage Determinations—The Pharmacy Benefits Manager, Navitus Health Solutions, reviews coverage requests and will provide a coverage decision to you and your prescriber. You may ask for an expedited coverage decision if you feel you need a fast decision.

     Medicare Part D Coverage Determination Request Form  online / printable

Appeals—if we deny coverage or payment for a prescription that you think we should cover or pay for, you may request an appeal. You can ask us to “expedite” or give you a quick decision if we have denied coverage (but not if your appeal is related to payment for services you already received).

     Medicare Part D Redetermination/Appeal Request Form  online / printable