Get Ny Healthfirst Request For Medicare Prescription Drug Coverage Determination 2020-2025

This guide provides clear, step-by-step instructions on how to effectively fill out the NY Healthfirst Request For Medicare Prescription Drug Coverage Determination form online. By following these guidelines, users can ensure their requests are properly submitted and addressed.

Follow the steps to complete your coverage determination request successfully.

1. Click 'Get Form' button to access the online request form.
2. Begin by entering the enrollee’s information. Include the enrollee’s full name, date of birth, address, city, state, zip code, phone number, and enrollee’s Member ID number.
3. If you are not the enrollee or the prescriber, provide the requestor’s name and their relationship to the enrollee. Fill in the requestor's address, city, state, zip code, and phone number.
4. Attach any necessary representation documentation to confirm the requestor's authority to represent the enrollee, if applicable.
5. Indicate the name of the prescription drug you are requesting, including the strength and quantity required per month.
6. Choose the type of coverage determination request from the available options and provide any necessary details related to your request.
7. If your prescriber supports your request, ensure their statement is attached to the form as it may be required.
8. Provide a detailed rationale for your request, including any relevant medical diagnoses, drug history, and supporting information that may assist in processing the request.
9. If needed, check the expedited review box if a quick decision is required due to urgent health concerns.
10. Lastly, ensure that all information is accurate, sign the form, and enter the date. Review the form to confirm completeness before submitting.
11. Once completed, save, download, or print the form for your records, or submit it as instructed.

Start filling out your document online today and ensure your prescription needs are met.