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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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Open the coverage-determination-request-form-2019-ks accessible pdf on your computer or mobile device.
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Read the instructions provided at the beginning of the form to familiarize yourself with the requirements.
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Begin filling out the form by entering your personal information such as your name, address, and contact details.
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Follow the section-wise instructions to accurately complete each section of the form.
05
Provide detailed information about the prescription medication for which you are seeking coverage determination.
06
If applicable, include any supporting documentation or additional information that may be required.
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Submit the completed coverage-determination-request-form-2019-ks accessible pdf as per the instructions provided.
Who needs coverage-determination-request-form-2019-ks accessible pdf?
01
Any individual who wishes to request a coverage determination for prescription medication in the state of Kansas would need the coverage-determination-request-form-2019-ks accessible pdf.
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