Request for Medicare Prescription Drug Coverage Determination

Step 1
Understanding Your Request Options

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: 1-800-208-9562).