Pharmacy coverage request form 2026

1. Click ‘Get Form’ to open the pharmacy coverage determination request form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, member ID number, date of birth, and contact details.
3. Next, complete the 'Prescriber Information' section. Input the prescriber's name, NPI number, office phone, and fax number.
4. In the 'Diagnosis and Medical Information' section, provide details about the medication including strength, route of administration, frequency, and expected length of therapy.
5. Indicate any allergies and include relevant diagnosis codes (ICD9) as required.
6. Ensure that you provide a rationale for exception requests in the designated area. Attach any necessary supporting medical records.
7. Finally, have the prescriber sign and date the form before submission.

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