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.
Requestor's information

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_2017_21 Approved 10172016
H9001_N_2017_16 Approved 10142016
The information on this page was last updated on 10/1/2016.

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.)