FEP Medicare Prescription Drug Program (MPDP)
A Medicare prescription drug benefit for eligible members who qualify for Medicare Part A and/or Medicare Part B utilizing Medicare as their Primary Health Care coverage.
MPDP Resources by Plan
MPDP Materials
MPDP Pharmacy Directory
View the network of pharmacies where you can fill your prescriptions.
Prescription Drug Transition Policy
Income-Related Monthly Adjustment Amount (IRMAA)
View information about Income-Related Monthly Adjustment Amount (IRMAA).
Enhanced Prior Approval Criteria
Additional drug coverage under this enhanced benefit may require prior approval before coverage is provided. View the list below for more information.
Appeal Request
If we have denied coverage or payment for a drug under your Medicare Part D benefit and you do not agree with our decision, you have the right to appeal the decision. View the document below for more information.
Mail Order Form
Use this form to request pharmacy prescriptions be mailed to you.
MPDP Disenrollment Form
Use the form that matches your benefits program (FEHB or PSHB) to disenroll from MPDP. Mail the completed form to FEP Medicare Prescription Drug Program, PO Box 3539, Scranton, PA 18505 or fax to 855-865-1817.
MPDP Claim Form
Use this form to submit your MPDP prescription claims via mail. Mail the completed form with receipts to CVS Caremark Medicare Part D Processing, P.O. Box 52066, Phoenix, AZ 85072-2066.
MPDP Utilization Management Forms
Formulary Exception Form
Use this form to request coverage of a drug that is not on your formulary. To process this request, your physician must provide a supporting statement documenting that all formulary alternatives would not be as effective or would have adverse effects.
Tier Exception Form
Use this form to request coverage of a brand or generic in a higher cost tier at a lower cost tier. Certain restrictions apply. To process this request, your physician must provide a supporting statement documenting that all of the drugs to treat the same medical condition on the lower cost tier would not be as effective or would have adverse effects.
Quantity Limit Exception Form
Use this form to request coverage of a quantity in excess of plan quantity limits. To process this request, your physician must provide a supporting statement explaining why the quantity allowed would not be as effective or would have adverse effects.
Step Therapy Exception Form
Use this form to request an exception to the plan step therapy requirement. Step therapy drugs are formulary drugs that are covered only if certain formulary alternatives have been tried first. To process this request, your physician must provide a supporting statement documenting that Step 1 medications have been tried or are likely to cause adverse effects.
Part D Model Coverage Determination and Redetermination Request Forms
Coverage Determination (Prior Authorization) Request Form
Use this form to request a coverage determination for a medication. Coverage determinations are inclusive of all types of requests that can be made regarding drug coverage, such as prior authorizations, exceptions, and reimbursement.
Redetermination Form
If your request for coverage of (or payment for) a prescription drug is denied, you have the right to ask for a redetermination (appeal) of the decision. You may use this form to request an appeal of this decision.
CMS Appointment of Representative Form (CMS Form-1696)
If you’re in MPDP and would like to appoint a person to file a grievance, request a coverage determination or request an appeal on your behalf, you and the person accepting the appointment must fill out this form and submit it with your request. Your prescribing physician or other prescriber may request a coverage determination, redetermination or IRE reconsideration on your behalf without having to be an appointed representative.
To view a Notice of Privacy Practices as required under the HIPAA Privacy Rule (45 CFR 164.520) click here.