Request for Pt D Coverage-Online Form

Request for Medicare Part D Prescription Drug Coverage


Please use this form to ask us to cover a Medicare Part D medication. When we receive this form, we will contact your provider to obtain the necessary information.

Part D Drug Coverage Determination Form

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If you are not the member or not an authorized representative of the member, a form will be sent to the member to authorize you to ask for this drug on their behalf.

Include strength and quantity, if known.

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