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.)