Medicare Part D forms

Coverage Determination

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs.

Use this form if you find out you need a “prior authorization” to get a medicine. This form cannot be used to get certain kinds of medicine, such as:

  • Fertility drugs
  • Drugs for weight loss or weight gain
  • Drugs for hair growth
  • Drugs for erectile dysfunction
  • Over-the-counter drugs
  • Prescription vitamins (except prenatal vitamins and fluoride preparations)

Use the online Medicare Part D Coverage Determination form  ►
- or -
Print a Medicare Part D Coverage Determination form (H2470_W_2015_11 Accepted 092614, pdf)

You can also get this form on the CMS website(This link takes you away from the Fallon Health Weinberg website.)

You can also call, write, or fax us, or ask your representative or doctor to ask us for a decision.


Calls to this number are free.




CVS Caremark
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

The doctor who told you to get the medicine will have to tell us why you need it. When we get the form from you, we will call the doctor to make sure that you need the medicine.


If Fallon Health Weinberg denied your prescription, you can use this form to ask us to change our decision.
Request for redetermination of Medicare prescription drug denial (H2470_W_2015_13, Accepted 09262014)

Medicare Part D Appeal

If we deny your request for coverage of a Part D drug, you may want to file an appeal. You can file an appeal within 60 days from the date that we denied your coverage. Once you tell us you want to appeal, we will send you a form to sign. If you or your doctor can’t sign the form, we will send a "Personal Representative Authorization - Filing an Appeal or Grievance" form. That form gives a person you choose the right to sign forms for you.
Medicare Part D Appeal Form ►

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. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year.

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Fallon Health Weinberg website.)

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

Find a doctor

Looking for a doctor? Need to see if your current doctor is in our network?

Search online

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)

Member information

2017 Summary of Benefits (H2470_W_2017_6_r1 Accepted 10152016) ►

2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf) ►

About the Medication Therapy Management Program

Covered medications

Find a doctor

Medicare Part D forms

Request for Medicare Part D prescription drug coverage determination
Use this form to initiate a prior authorization request for your medication.

Request for a Medicare Part D appeal
Use this form to initiate an appeal for a denied medication.