Commonwealth Care Alliance

Senior Care Options Program (HMO SNP)

Pharmacy » Prescription Coverage » Pharmacy Forms

Pharmacy Forms

  • Download the Model Drug Coverage Determination Form (pdf)
  • Download the Request for Redetermination of Medicare Prescription Drug Denial Form (pdf)

Your doctor must submit a statement supporting your request. The doctor’s statement must indicate that the requested drug is medically necessary for treating your condition because none of the drugs we cover for your condition would be as effective as the requested drug or would have adverse effects for you. If the exception involved a prior authorization, quantity limit, or other limit we have placed on a drug you are taking, the doctor’s statement must indicate that the prior authorization or limit would not be as effective for treating your condition or would have adverse effects for you.

See Chapter 8 of your Evidence of Coverage (Member Handbook) for more information on exceptions, appeals, and grievances.

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Last Updated 10/28/2016