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INSTRUCTIONS FOR COMPLETION
Request for Medicare Prescription Drug Coverage Determination
The following must be completed for the request to be processed. Failure to complete these items may result in a delay of your request:
- Enrollee’s Name
- Enrollee’s Date of Birth
- Enrollee’s Medicare Number
- Enrollee’s Plan Identification Number
- Requestor’s Name – If not the Enrollee
- Requestor’s relationship to the Enrollee and the attached supporting documentation
- Contact Phone Number
- Name of prescription drug being requested*
- All information regarding the physician who has prescribed the medication
- Check all boxes under the heading “Type of Coverage Request”
- Name
- Signature
*A separate form must be completed for each prescription drug.
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