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COVERAGE DETERMINATION REQUEST FORM EOC ID: Tier Exception (TE)1 Medicare Phone: 8662502005Fax back to: 8775037231Rx manages the pharmacy drug benefit for your patient. Certain requests for coverage
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Fax back to 877-503-7231 is a form that needs to be completed and sent back via fax to the specified number.
Anyone who has received the fax back form and is requested to fill it out needs to file it to 877-503-7231.
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