Get 2020 Medicare Coverage Determination Request Form

Filling out the 2020 Medicare Coverage Determination Request Form online can be a straightforward process if you follow the outlined steps. This guide will walk you through each section of the form to ensure you provide the necessary information to support your coverage request.

Follow the steps to conveniently complete your request online.

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 name, date of birth, address, phone number, and member ID number.
3. If the request is being made by someone other than the enrollee or prescriber, fill in the requestor’s name, their relationship to the enrollee, and their contact information.
4. Indicate the name of the prescription drug being requested, along with its strength and the quantity requested per month.
5. Select the type of coverage determination request from the provided options, ensuring the prescriber provides a supporting statement if necessary.
6. For additional information, attach any supporting documents that may strengthen your request for coverage.
7. If applicable, check the box to indicate a request for an expedited decision, ensuring you include a supporting statement from your prescriber.
8. Have the prescriber fill out their information, including their name, contact details, and signature, if they are involved in the request.
9. In the diagnosis and medical information section, provide details about the medication, relevant medical history, and any drug allergies.
10. Lastly, review all sections for accuracy, and save changes. You may download, print, or share the completed form as needed.

Start completing your 2020 Medicare Coverage Determination Request Form online today.