Request for Medicare Prescription Drug Coverage Determination

This form may be sent to us by mail or fax:

CareSource
c/o CVS Caremark
MC109
P.O. Box 52000
Phoenix, AZ, 85072-2000
Fax Number
1-855-633-7673
Information

You may also ask us for a coverage determination by phone at 1-855-475-3163 (TTY 1-800-750-0750 or 711).

or through our website at: https://www.caresource.com/mycare/ We are open 8 a.m. - 8 p.m. Monday through Friday and from Oct. 1 - Feb. 14 we are open the same hours 7 days a week.

Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee's Information

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Representation documentation for requests made by someone other than enrollee or the enrollee’s prescriber:

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare.


Type of Coverage Determination Request









*NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement), may require supporting information. Your prescriber may use the attached “Supporting Information for an Exception Request or Prior Authorization” to support your request.

Important Note: Expedited Decisions

If you or your prescriber believe that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.

If you have a supporting statement from your prescriber, attach it to this request.

Supporting Information for an Exception Request or Prior Authorization

FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber’s supporting statement. PRIOR AUTHORIZATION requests may require supporting information.

Prescriber's Information
Diagnosis and Medical Information
Rationale for Request





CareSource® MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.

H8452_OHMMC207
CMS Approved 4/30/2014