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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorization Department P.O. Box 419069 Rancho Cordova, CA

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Locate the fillable fields in the form, indicated by highlighted areas or text boxes.

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Start by entering your personal information, such as your name, date of birth, and contact details in the appropriate fields.

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Move on to the section where you need to provide information about your health insurance plan. Fill in the details like your insurance ID number, policyholder's name, and any relevant group numbers.

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If applicable, provide information about the medication or treatment for which you are seeking coverage determination. Include details such as the drug name, dosage, frequency, and the reason for the request.

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Individuals who are seeking coverage determination for their health insurance plan in California may need the coverage-determination-request-form-2019-ca accessible pdf. This form is specifically designed for Californian residents who require a formal request for coverage determination related to their insurance benefits. It can be used by individuals, healthcare professionals, or authorized representatives who are advocating for coverage of specific medications or treatments under their health insurance plan.

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