To submit this form, send it by mail to OPTUMRx Prior Authorization Dept., M/S CA106-0268, 3515 Harbor Blvd., Costa Mesa, CA 92626. Alternatively, fax it to 1-800-527-0531 for standard requests or 1-800-853-3844 for specialty requests. You may also request a coverage determination by phone at 1-800-711-4555 or through the website at www.OptumRx.com. Ensure all sections are filled out, attach necessary supporting documents, and include any prescriber's statements. My advice: double-check all information and documentation before submission to avoid delays.

Ensure timely submission of the form for coverage determinations, especially if you need a decision within 24 hours. Important dates for 2024 and 2025 will be communicated by your Medicare plan provider.

The purpose of this form is to request a Medicare prescription drug coverage determination. It provides a structured way for enrollees or their representatives to request prior authorizations, exceptions to drug quantity limits, lower copayments, or reimbursements for out-of-pocket drug costs. By using this form, you can ensure that your request is reviewed and processed efficiently.

• 1. Enrollee's Information: This section captures the personal and contact details of the Medicare enrollee.
• 2. Requestor's Information: If someone other than the enrollee or prescriber is making the request, this section collects their details and relationship to the enrollee.
• 3. Prescription Drug Details: Provide information about the drug being requested, including name, strength, and quantity.
• 4. Type of Coverage Determination Request: Indicate the specific type of request being made, such as formulary exception, prior authorization, or tiering exception.
• 5. Supporting Documents: Attach any necessary supporting documents, including prescriber's statements and authorization of representation forms.
• 6. Signature and Date: The form must be signed and dated by the enrollee, requestor, or prescriber.
• 7. Prescriber's Information: Capture the prescriber's details, including name, contact information, and signature.
• 8. Diagnosis and Medical Information: Provide relevant medical information, including diagnosis, medication details, and rationale for the request.

Failing to submit this form could result in delays or denials for the requested Medicare prescription drug coverage.

• Delayed Access to Medication: Without submitting the request form, you may experience delays in obtaining necessary medications.
• Denial of Coverage: Failure to provide required documentation and information may lead to denial of the coverage request.
• Increased Out-of-Pocket Costs: Not completing the form could result in higher costs for medications due to lack of coverage determination.

• 1. Formulary Exception: Request coverage for a drug not on the plan's list of covered drugs.
• 2. Prior Authorization: Seek prior authorization for a prescribed drug.
• 3. Quantity Limit Exception: Request an exception to the plan's limit on the number of pills or medication quantity.
• 4. Tiering Exception: Ask for a lower copayment for a prescribed drug compared to another drug.
• 5. Reimbursement Request: Request reimbursement for a covered prescription drug paid for out-of-pocket.