Because Todays Options PPO denied your request for coverage of (or payment for) a prescription drug, you have the right 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Enrollee’s Information section. Enter your name, date of birth, address, city, state, zip code, phone number, and Plan ID Number.
3. If someone other than the enrollee is making the request, complete the Requestor’s Information section with their name, relationship to enrollee, address, city, state, zip code, and phone number.
4. In the Prescription Drug section, specify the name of the drug you are appealing for and its strength/quantity/dose. Indicate whether you have purchased the drug pending appeal and provide details if applicable.
5. Fill out the Prescriber’s Information with their name, address, phone number, and fax number.
6. If requesting an expedited decision due to health concerns, check the appropriate box and attach any supporting statements from your prescriber.
7. Finally, sign and date the form at the bottom before submitting it via mail or fax as indicated.

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