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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Blue Cross Medicare Rx (PDP)SM Attn: Clinical Review Department 1305 Corporate Center
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What is this form may be?
This form may be a tax return form.
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Individuals or businesses with taxable income may be required to file this form.
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This form may be filled out by providing accurate financial information and supporting documentation.
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The purpose of this form may be to report income and calculate taxes owed.
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Information such as income, expenses, deductions, and credits may be reported on this form.
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