Follow these steps in requesting a Part D Coverage Determination.

I. MEMBER INFORMATION
Please complete this section as follows:
As a SCAN member you may file a Grievance and/or Appeal or you can appoint a relative, friend, advocate, doctor, attorney, or other person to act for you. If you already have an authorized representative under state law to act for you, this person may file a Grievance and/or Appeal. If you would like to appoint a representative to file a Grievance and/or Appeal on your behalf please reference the CMS Appointment of Representation form (Form CMS-1696)

www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf

Member Name
Member Date of birth
Member Medicare Number
Member ID number - This can be found on your SCAN membership card

If you are filing a Coverage Determination on behalf of a member and you want to receive a response to the Coverage Determination as well, please complete the following fields on the form:

Requestor Name
Requestor’s relationship to member (must submit documentation that shows authority to represent member, if other than prescribing physician)

Member/Requestor’s Address
Member/Requestor’s Phone number

II. NAME OF PRESCRIPTION DRUG REQUEST
This identifies the Part D prescription drug you are requesting a Coverage Determination.

III. PRESCRIBING PHYSICIAN’S INFORMATION
If a prescribing physician is requesting a Coverage Determination on behalf of a member; please complete the following fields on the form:

Physician Name
Medical Specialty
Physician Address
Physician Phone Number, and Physician Fax Number
Physician Office Contact Person

IV. TYPE OF COVERAGE DETERMINATION REQUEST
Review and check the box that pertains to the reason a Coverage Determination is being requested.

V. WHEN FINISHED
Click the submit button to send your form to SCAN. We suggest that you print a copy for your records.

This form cannot be used to request barbiturates, benzodiazepines, fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations)

	Enrollee’s Name	Enrollee’s Date of Birth

	Enrollee’s Medicare Number	Enrollee’s Part D Plan ID Number

	Requestor’s Name (if not enrollee)

	Requestor’s relationship to Enrollee (attach documentation that shows authority to represent enrollee, if other than prescribing physician)

			Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Enrollee/Requestor’s Address	City	State	Zip Code

	Phone

	Name of prescription drug you are requesting (if known, include strength, quantity and quantity requested per month)

	Physician's Name	Medical Specialty

			Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Address	City	State	Zip Code

	Work Phone	Fax	Office Contact Person

		I need a drug that is not on the plan’s list of covered drugs (formulary exception).*

		I have been using a drug that was previously included on the plan’s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).*

		I request an exception to the requirement that I try another drug before I get the drug my doctor prescribed (formulary exception).*

		I request prior authorization for the drug my doctor has prescribed.

		I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my doctor prescribed (formulary exception).*

		My drug plan charges a higher copayment for the drug my doctor prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).*

		I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).*

		I want to be reimbursed for a covered prescription drug that I paid for out of pocket.

	Additional information we should consider (attach any supporting documents):

		I need an expedited coverage determination (attach physician’s supporting statement, if applicable)

CMS 041206 SCAN 2313-2006F H9104 / H5425 / H5943