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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: 3601 SW Murray Blvd Suite 10C Beaverton, OR 97005Fax Number: (503) 5748646 18002497714You

How to fill out drug coverage determination form

How to fill out drug coverage determination form

1. To fill out the drug coverage determination form, follow these steps:
2. Start by providing your personal information, such as your name, address, phone number, and date of birth.
3. Indicate the specific drug that you are seeking coverage for. Include the drug name, dosage, and frequency of use.
4. Explain the medical condition for which you require the drug and provide any supporting documentation from your healthcare provider.
5. If you have previously tried other medications for the same condition, list them and describe why they were not effective or caused adverse reactions.
6. Describe the expected benefits of the requested drug and how it will improve your medical condition or quality of life.
7. Provide any additional information or documentation that may support your case, such as relevant medical records or test results.
8. Sign and date the form, certifying that the information provided is truthful and accurate.
9. Submit the completed form to your insurance provider or pharmacy as instructed.

Who needs drug coverage determination form?

1. Anyone who wishes to obtain coverage for a specific drug from their insurance provider needs to fill out the drug coverage determination form. This form is typically required when an individual's prescribed medication is not listed on the insurance plan's formulary or requires prior authorization. It is also necessary for individuals who have tried other medications without success or experienced adverse reactions, as they may need to provide additional information to support their request for coverage.

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