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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Express Scripts Inc Attn: Medicare Reviews PO BOX 66571 St. Louis, MO 63166-6571

How to fill out coverage determination request form

How to Fill Out a Coverage Determination Request Form:

1. Start by obtaining a blank coverage determination request form from your insurance provider. This form can usually be found on their website or you can request a physical copy from their customer service department.
2. Begin filling out the form by providing your personal information such as your name, address, date of birth, and insurance policy number. This information is necessary for your insurance provider to accurately identify you and your coverage.
3. Next, provide detailed information about the prescription drug or medical service that you are seeking coverage for. Include the name of the medication, the dosage, and the frequency at which you need to take it. If it's a medical service, describe the procedure or treatment you require.
4. Include any relevant medical documentation to support your request. This can include doctor's notes, prescriptions, test results, or any other documentation that demonstrates the medical necessity of the drug or service.
5. Indicate whether you have tried any alternative medications or treatments in the past and provide a brief explanation if applicable. This helps your insurance provider evaluate the necessity of the requested medication or service.
6. If you have been prescribed a medication and there is no generic alternative available, indicate this on the form. Some insurance plans may require this information for coverage determination purposes.
7. Review the form to ensure all the required information is provided and that it is filled out clearly and legibly. Any missing or unclear information may result in a delay or denial of your coverage determination request.

Who Needs a Coverage Determination Request Form:

1. Individuals who have a prescription for a medication not covered by their insurance plan.
2. Patients who require a medical service or procedure that may or may not be covered by their insurance.
3. Those who have tried alternative medications or treatments without success and require coverage for a specific drug or treatment.

Remember, it is always best to consult your insurance provider or healthcare professional if you have any specific questions or concerns about filling out a coverage determination request form.

For pdfFiller’s FAQs

What is coverage determination request form?

Coverage determination request form is a document used to ask a health insurance plan to make a decision about what medical care or prescription drug benefits are covered under the plan.

Who is required to file coverage determination request form?

Anyone who wants their health insurance plan to decide if a particular treatment or prescription drug is covered under their policy is required to file a coverage determination request form.

How to fill out coverage determination request form?

Coverage determination request form can usually be filled out online, over the phone, or by mail. It typically requires providing details about the treatment or prescription drug in question, as well as personal and insurance information.

What is the purpose of coverage determination request form?

The purpose of coverage determination request form is to request a decision from the health insurance plan about whether a specific medical treatment or prescription drug is covered under the policy.

What information must be reported on coverage determination request form?

Information such as the specific medical treatment or prescription drug in question, details about the patient's condition, insurance policy details, and any supporting documentation may need to be reported on the coverage determination request form.

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