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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MM/DD/YYYY

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.

Include area code.

Include area code.

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