Request for Medicare Part D prescription drug coverage determination

Use this form to initiate a prior authorization request for your Medicare Part D medication. This form cannot be used to request fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, drugs for erectile dysfunction, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

Your prescribing provider must provide a statement to support your request. When we receive your request, we will contact your provider to obtain the necessary information.

* Indicates a required field.

Member information
Date of birth
Complete the following section ONLY if the person
making this request is not the member or prescriber.
All fields are required.
Medication information
Prescribing provider’s information
Additional information we should consider

Fallon Health is an HMO/HMO-POS plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal.

H9001_F_2018_24 Approved 10102017
H9001_N_2018_10 Approved 10192017
The information on this page was last updated on 10/1/2017.

Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)