Get Medicare Part D Coverage Determination Request Form

This guide provides clear and supportive instructions for users filling out the Medicare Part D Coverage Determination Request Form online. Understanding each section of the form can help facilitate the process of obtaining necessary prescription drug coverage.

Follow the steps to complete the request form accurately

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Enter the enrollee’s information in the designated fields, including their name, date of birth, address, phone number, and member ID.
3. If you are not the enrollee or prescriber making this request, complete the requestor's information section, including your name, relationship to the enrollee, and your contact details.
4. Specify the name of the prescription drug you are requesting. If known, include the strength and quantity you are seeking per month.
5. Select the type of coverage determination request from the options provided. Make sure to review the notes regarding the necessity of a prescriber’s supporting statement for certain requests.
6. Provide any additional information that may support your request. This includes uploading any necessary supporting documents.
7. If you believe expedited review is necessary, check the corresponding box and ensure you have a supporting statement from the prescriber.
8. Sign and date the request form, ensuring that the signature is from the person making the request (enrollee, prescriber, or representative).
9. Once all required fields are completed, save your changes. You may also download, print, or share the form as needed.

Complete your Medicare Part D Coverage Determination Request Form online today to ensure timely processing of your request.