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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
This form may be sent to us by mail or fax:
Address:
EnvisionRxPlus
2181 E. Aurora Rd., Suite 201
Twins burg, OH 44087
Attn: Clinical
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How to fill out is it truehttpswwwclearspringhealthcarecomstaticdocsmembersplandrugenvision20rx20request20for20medicare20rx20coverage20determinationpdf
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To fill out the 'Is it True?' document for Medicare RX coverage determination, follow these steps:
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Visit the website 'https://www.clearspringhealthcare.com/static/docs/members/plan_drug/envision_rx_request_for_medicare_rx_coverage_determination.pdf'
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Fill in your personal information accurately, including your name, contact details, and Medicare information.
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Provide the details of the medication for which you are seeking coverage determination.
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Answer the questions in the form accurately and truthfully, providing any supporting documentation if required.
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Save a copy of the filled-out form for your records.
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Submit the completed form to the appropriate Medicare or healthcare provider as instructed on the form.
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This is a form for requesting coverage determination for Medicare Part D prescription drugs.
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Members enrolled in a Medicare Part D plan may be required to file this form.
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The purpose of this form is to request coverage determination for Medicare Part D prescription drugs.
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Information such as the member's details, the prescription drug information, and the reason for coverage determination request must be reported.
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