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Plan Name Phone # Fax # Medicare Part D Coverage Determination Request Forms form cannot be used to request: Medicare noncovered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs

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This form cannot be used for tax purposes.

Who is required to file this form cannot be?

This form cannot be filed by individuals under the age of 18.

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This form cannot be filled out electronically.

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This form cannot be used for requesting medical records.

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