INSTRUCTIONS FOR COMPLETION
Medicare Part D Coverage Determination Request Form

The following items must be completed before the request can be processed.  An incomplete form or failure to attach supporting documents may delay processing of the request.

1. Completion of all items under “Patient Information”
2. Completion of all items under “Prescriber Information”
3. Completion of all items under “Diagnosis and Medical Information”
4. Check at least one box under “Rationale for Exception Request or Prior Authorization”

• Determination Request Form
  

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