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Medicare Prescription Drug Coverage Request




Enrollee Information

First Name
Middle Initial
Last Name
Date of Birth
Enrollee’s Member ID #
Street One
Street Two
City
Zip
Phone

Prescription Drug Requests

Drug Name
Strength
Quantity

Type of Request

Expedited Decisions

Prescriber Information

First Name
Middle Initial
Last Name
Street One
Street Two
City
Zip
Phone
Fax

Additional Information

Signature
Notes
Supporting Document
PDF Format
Representation Authorization Form CMS-1696 or written equivalent
PDF Format