FEP Medicare Prescription Drug Program (MPDP)

MPDP Pharmacy Directory

View the network of pharmacies where you can fill your prescriptions.

MPDP Pharmacy Directory

Prescription Drug Transition Policy

Prescription Drug Transition Policy

Income-Related Monthly Adjustment Amount (IRMAA)

View information about Income-Related Monthly Adjustment Amount (IRMAA).

Visit medicare.gov

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.

2025 Enhanced Prior Approval Criteria (English)

2025 Enhanced Prior Approval Criteria (Spanish)

2024 Enhanced Prior Approval Criteria (English)

2024 Enhanced Prior Approval Criteria (Spanish)

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.

MPDP Appeal Request Document

Mail Order Form

Use this form to request pharmacy prescriptions be mailed to you. 

MPDP Mail Order Form

MPDP Disenrollment Form

Use this form 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 Claim Form

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.

English

Spanish

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.

English

Spanish

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.

English

Spanish

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.

English

Spanish

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. 

English

Spanish

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.

English

Spanish

Reconsideration Form

If the initial decision to deny coverage of (or payment for) a prescription drug is upheld after an appeal you have the right to ask for an independent review of this decision. You may use this form to request an independent review of your drug plan’s decision.

English

Spanish