Get Request For Medicare Prescription Drug Coverage Determination

The Request For Medicare Prescription Drug Coverage Determination form is an essential document for users seeking specific prescription drug coverage. This guide provides a clear and supportive step-by-step approach to help you complete the form online with ease.

Follow the steps to complete your request smoothly.

1. Click ‘Get Form’ button to access the Request For Medicare Prescription Drug Coverage Determination form and open it.
2. Provide the enrollee's information by entering their name, date of birth, address, city, state, zip code, phone number, and member ID.
3. If the requestor is not the enrollee or prescriber, fill out the requestor's name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. Attach any representation documentation if someone other than the enrollee or the prescriber's making the request. This includes the Authorization of Representation Form or a written equivalent.
5. Indicate the name of the prescription drug being requested, including the strength and quantity needed per month.
6. Select the type of coverage determination request by checking the appropriate box for your specific situation, such as formulary exception, prior authorization, or tiering exception.
7. If applicable, provide any additional information and attach supporting documents that may assist in the decision-making process.
8. Check the box if an expedited decision is needed and attach a supporting statement from your prescriber if available.
9. Remember to sign and date the form to certify that the information provided is true and complete.
10. Once completed, you can save changes, download, print, or share the form, and submit it as per the required process.

Fill out your Request For Medicare Prescription Drug Coverage Determination online today to ensure you receive the prescription coverage you need.