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 Weinberg is an HMO plan with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Fallon Health Weinberg depends on contract renewal.

H2470_W_2017_7 Approved 10182016
The information on this page was last updated on 10/1/2017.

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Download the Provider and Pharmacy Directory (H2470_W_2017_26_r1_NM, pdf)

Contact us

Information before enrolling:
1-855-561-7248 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

Customer Service:
1-855-561-7247 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)