Get 8003386180

Filling out the 8003386180 form, also known as the request for Medicare prescription drug coverage determination, is essential for those seeking coverage for specific medication needs. This guide provides clear instructions for completing the form online to ensure a successful submission.

Follow the steps to complete the request for Medicare coverage determination.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the enrollee's information, including their full name, date of birth, address, city, state, zip code, phone number, and member ID number.
3. If a requestor is submitting the form on behalf of the enrollee, fill in their name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. Attach any representation documentation if the request is made by someone other than the enrollee or prescriber. This includes the Authorization of Representation Form CMS-1696 or a similar written document.
5. Provide the name of the prescription drug being requested, including strength and quantity required per month.
6. Select the reason for the coverage determination request from the options given, such as needing a drug not on the formulary or requesting prior authorization.
7. Add any additional information that may support your request, including explanations for the necessity of the drug or any medical conditions.
8. If applicable, indicate if you believe you need an expedited decision by checking the provided box and attaching any supporting statements from the prescriber.
9. Sign and date the form either as the enrollee, prescriber, or authorized representative.
10. Save changes, download, print, or share the form as necessary after filling it out.

Complete your request for Medicare drug coverage today by filling out the form online!