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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Fax Number: (866) 2901309Address: 7050 Union Park Center Drive Suite 200 Midvale, Utah 84047You
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How to fill out coverage determination request
How to fill out coverage determination request
01
Obtain the coverage determination request form from your insurance provider.
02
Fill out all required fields on the form, including your personal information, policy number, and details about the prescription or medical service in question.
03
Attach any supporting documentation, such as a doctor's prescription or medical records, to the form.
04
Submit the completed form and any additional documents to the address provided by your insurance provider.
05
Wait for a response from the insurance provider regarding the coverage determination request.
Who needs coverage determination request?
01
Individuals who have been prescribed a medication or recommended a medical service that may not be covered by their insurance.
02
Patients who are seeking approval for coverage of a specific prescription drug or medical treatment.
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What is coverage determination request?
A coverage determination request is a formal process where a Medicare beneficiary or their prescriber requests that a Part D plan make a decision about covering a prescription medication.
Who is required to file coverage determination request?
A Medicare beneficiary or their prescriber is required to file a coverage determination request.
How to fill out coverage determination request?
To fill out a coverage determination request, the beneficiary or prescriber must provide information about the medication being requested, including medical necessity.
What is the purpose of coverage determination request?
The purpose of a coverage determination request is to have a Part D plan make a decision about covering a prescription medication.
What information must be reported on coverage determination request?
The coverage determination request must include information about the medication being requested, the medical necessity for the medication, and any supporting documentation.
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