Prescription Drug Coverage Appeal Form
Patient Information
Full Name
Date of Birth
Member ID/Policy Number
Phone Number
Prescriber Information
Prescriber Name
Phone Number
Fax Number
NPI
Drug Information
Drug Name
Dosage/Strength
Quantity
Directions for Use
Reason for Appeal
Supporting Information
Medical Justification
Previous Medications Tried
Contact Information for Notification
Contact Name
Contact Phone
Contact Email