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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Blue Medicare Rx Appeals Department MC 109 PO Box 52000 Phoenix, AZ 850722000 Fax

How to fill out request for medicare prescription

How to Fill Out a Request for Medicare Prescription:

1. Start by gathering all the necessary information. You will need your Medicare card, a list of the medications you take, the name and contact information of your prescribing doctor, and your personal information such as name, address, and contact details.
2. Begin by filling out the "Patient Information" section of the request form. Include your full name, address, phone number, and any other relevant details. Double-check to ensure accuracy.
3. Moving on to the "Prescription Information" section, provide the details of the medications you require. Include the name, dosage, and any other specific instructions or comments related to each medication. Be precise and clear to avoid any confusion.
4. If you have additional medications to list, use extra space provided or attach an additional sheet if necessary. Make sure to label it with your name and other identifying information.
5. If there are any special conditions or requirements, such as the need for a brand-name medication due to medical necessity, be sure to indicate this in the appropriate section of the form. Provide any supporting documentation or notes from your doctor if required.
6. Review the completed form thoroughly to check for any errors or missing information. It is crucial to provide accurate details, as mistakes can lead to delays or denials in the prescription approval process.
7. Once you are confident that the form is accurate and complete, sign and date it. This signature ensures that you authorize the release of your medical information and allow Medicare to process your prescription request.

Who needs a request for Medicare prescription?

1. Individuals who are enrolled in Medicare and require prescription medications.
2. Those who have recently joined a Medicare prescription drug plan and need to request medication coverage.
3. Individuals who have changed medications or dosage and need to update their prescription information with Medicare.
4. Patients who need a specific brand-name medication due to medical necessity and require approval from Medicare.

Remember, if you have any doubts or questions about filling out the request form, do not hesitate to contact your Medicare prescription plan provider or reach out to a Medicare representative for assistance.

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