Get H3528 Y0026 122931r Part D Coverage Determination Request Form 2.doc

The H3528 Y0026 122931r Part D Coverage Determination Request Form is essential for users seeking coverage for specific prescription medications under Medicare. This guide will provide you with clear and supportive instructions to successfully complete the form online.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling in the enrollee's information. Provide the enrollee’s full name, date of birth, address, city, state, zip code, phone number, and plan ID number.
3. If the request is being made by someone other than the enrollee or prescriber, complete the requestor’s section with the name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. Attach any necessary documentation showing authority to represent the enrollee, such as the completed Authorization of Representation Form CMS-1696 or a written equivalent.
5. Indicate the name of the prescription drug being requested, including its strength and the quantity per month.
6. Select the type of coverage determination request that applies. This includes options such as formulary exceptions, prior authorization, and tiering exceptions. Make sure to check all relevant boxes.
7. If applicable, provide additional information or supporting documents needed to consider the request.
8. If expedited decisions are required, check the appropriate box and ensure a supporting statement from the prescriber is attached.
9. Sign and date the form in the signature section. The signature must belong to the enrollee, their prescriber, or their representative.
10. Fill in the prescriber’s information and include the required medical details such as diagnosis and any previous medications tried.
11. Review all entries for accuracy before saving the completed form. You may then download, print, or share the form as needed.

Take action now by completing your coverage determination request online.