Request for Medicare Part D coverage determination

Use this form to start 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

First name

Last name

Member ID number

Date of birth

MonthDayYear

Phone number (with area code)

Complete the following section ONLY if the person
making this request is not the member or prescriber.
All fields are required.

Requestor's first name

Requestor's last name

Requestor’s relationship to enrollee

Requestor's phone number (with area code)

Medication information

Name of prescription drug you are requesting (if known, include strength, directions and quantity).

Prescribing provider’s information

First name

Last name

Address

City

State

ZIP code

Office phone number (with area code)

Office fax number (with area code)

Office contact person (other than provider)

Additional information we should consider

Please use this space for any additional comments you may have.

Call us toll-free at 1-800-325-5669 (TRS 711), Monday–Friday, 8 a.m.–8 p.m.
(Oct. 1–March 31, seven days a week.)

H9001_210082_C
H9001_210085_C
The information on this page was last updated on 10/1/2020.

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

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One Chestnut Place, 10 Chestnut Street, Worcester, MA 01608
1-888-340-5504 (TRS 711) | MedicareSalesOperations@fallonhealth.org

Anonymous Compliance Hotline: 1-888-203-5295 (toll-free)
Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse.
You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.

Multi-language Interpreter Services (H9001_N_2017_32 Accepted 08282016, pdf)
Notice of non-discrimination (pdf)

For information in other languages:

One Chestnut Place, 10 Chestnut Street, Worcester, MA 01608
1-800-868-5200 (TRS 711), Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

Notice of non-discrimination (pdf)

For information in other languages:

English	Tiếng Việt	Français	Polskie
Español	Pусский	Italiano	हिंदी
Português	العربية	한국어	ગુજરાતી
中文	វៀតណាម	ελληνικά	ລາວ

Anonymous Compliance Hotline: Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse. You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.