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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form cannot be used to request barbiturates, benzodiazepines, fertility drugs, drugs for weight loss or weight gain, drugs for hair
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What is this form cannot be?
This form cannot be used for tax purposes.
Who is required to file this form cannot be?
Individuals under the age of 18 are not required to file this form.
How to fill out this form cannot be?
This form cannot be filled out electronically.
What is the purpose of this form cannot be?
The purpose of this form cannot be to request a refund.
What information must be reported on this form cannot be?
Personal medical information must not be reported on this form.
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