Request for Medicare Prescription Drug Coverage Determination

Step 1

Understanding Your Request Options

You are about to fill out an online form requesting Medicare prescription drug coverage.

Depending on your situation, your request may require additional information from your prescriber. You can submit this form in two ways:

Use Online Form: Continue with Online Request
Fill out the request form here and submit it digitally. If additional information is required, we will contact your prescriber.

Or

Print, Mail or Fax: Print & Complete a Hard Copy
Print the entire request form now. Fill out your information and mail the completed hard copy to us directly.

Please Note: This form cannot be used to request fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

If you would prefer, you can also ask for coverage determination by phone at 1-800-701-9000 (TTY: 711).