New Medicare Drug Plan Exception and Prior Authorization Request Form

To further the goal of simplifying procedures in the new drug benefit, the American Medical Association (AMA) and America's Health Insurance Plans (AHIP), in conjunction with Centers for Medicare & Medicaid Services (CMS), released a standardized form designed to assist physicians in applying for exceptions and prior authorizations on behalf of Medicare recipients enrolled in Medicare drug plans. The Medicare Part D Coverage Determination Request Form assists physicians in applying for coverage determinations on behalf of their Medicare recipients, regardless of the Part D plan in which their recipients are enrolled.

The Medicare Part D Coverage Determination Request Form is available on the CMS Web site. To view, click the “Exceptions Request Form” link in the "Part D Tools for Health Care Professionals" section of the CMS Provider Center page.