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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: My Choice Wisconsin Medicare Dual Advantage ATTN: Pharmacy Services 1617 Sherman Ave Madison,
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How to fill out coverage-determination-request - my choice

01
Gather all relevant information including the patient's information, prescriber's information, drug name, strength, and quantity.
02
Complete the Coverage Determination Request Form which can usually be found on the insurance company's website or obtained from the prescriber's office.
03
Include any necessary supporting documentation such as medical records, prior authorization forms, or clinical notes.
04
Submit the completed form and supporting documentation to the insurance company via fax, mail, or online portal.
05
Follow up with the insurance company to ensure that the request has been received and processed in a timely manner.

Who needs coverage-determination-request - my choice?

01
Individuals who need coverage for a specific medication that may not be covered by their insurance plan or requires prior authorization.
02
Healthcare providers who are prescribing a medication that may require prior authorization or have a coverage issue with the patient's insurance.
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A coverage determination request is a formal request submitted to an insurance company or healthcare provider to determine whether a specific medical service or treatment is covered under the terms of the insurance policy.
Anyone who is seeking coverage for a medical treatment or service that may not be clearly covered by their insurance policy is required to file a coverage determination request.
To fill out a coverage determination request, one must provide detailed information about the medical treatment or service in question, along with any supporting documentation or medical records that may be relevant.
The purpose of a coverage determination request is to receive a formal decision from the insurance company or healthcare provider regarding coverage for a specific medical treatment or service.
Information that must be reported on a coverage determination request typically includes details about the medical treatment or service, relevant medical history, and any supporting documentation or evidence.
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