Request for Coverage Determinations and Redetermination

MEMBER INFORMATION

First Name

Last Name

Phone Number

e.g. (000) 000 - 0000

Street Address

Apartment or Unit Number (optional)

City

State

ZIP Code

e.g. 00000

Member ID

Enter a three-character prefix, then numerical digits.

Drug Name

How many pills for this medication do you take per day?

Reason for taking this medication

Have you tried other medications?

Yes

Prescribing Physician Name

Prescribing Physician Phone Number

e.g. (000) 000 - 0000

Prescribing Physician Fax Number (optional)

e.g. (000) 000 - 0000

Prescribing Physician NPI (optional)

Do you have a current supply of this medication?

Yes

Who is making this request? (optional)

Self

Physician

Other

All fields are required unless noted optional.

If you'd prefer to contact us, call 1-888-995-2583 (TTY: 711).

April 1 - September 30
8:00 a.m. - 8:00 p.m. ET, Monday - Friday

October 1 - March 31
8:00 a.m. - 8:00 p.m. ET, Seven days a week