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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Trillium Community Health Plan P.O. Box 11756 Eugene, OR 974403956 Fax Number: 5419845686

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. This includes your personal information such as your full name, address, date of birth, and Medicare number. You will also need the name and address of your prescribing doctor or healthcare provider.
2. Next, download or request a copy of the Medicare prescription request form. You can usually find this form on the Medicare website or by contacting your local Medicare office. Make sure you have the most up-to-date version of the form.
3. Fill in your personal information accurately and legibly on the form. Double-check that you have entered your Medicare number correctly as any mistakes can cause delays in processing your request.
4. Provide the information about the prescription medication you are requesting. This includes the medication name, dosage, and quantity. If you have the original prescription from your doctor, make sure to attach it to the form.
5. Indicate how you would like to receive your prescription, either by mail or by picking it up at a local pharmacy. If you choose mail delivery, provide the address where you would like the prescription to be sent.
6. If you have any additional notes or special instructions for the pharmacist, you can include them in the designated section of the form.
7. Finally, review the completed form for any errors or missing information. Ensure that you have signed and dated the form before submitting it.

Who needs a request for Medicare prescription?

1. Medicare beneficiaries who require prescription medications.
2. Individuals who are enrolled in a Medicare Part D prescription drug plan.
3. People who have a Medicare Advantage plan with prescription drug coverage.
4. Patients who need to obtain prescription drugs covered by Medicare.

Remember, if you have any questions or need assistance in filling out the request for Medicare prescription form, you can reach out to your local Medicare office or contact the Medicare helpline for guidance.

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