• Request for Medicare Part D Prescription Drug Coverage

Request for Medicare Part D Prescription Drug Coverage Determination

Use this form to initiate a request for a Medicare Part D medication. When we receive your request, we will contact your provider to obtain the necessary information.

* Indicates a required field

Member information

Date of birth


Requestor Information

Complete the following section. All fields are required.


Medication Information

*Name of prescription drug you are requesting (if known, include strength, directions and quantity).


Prescribing provider’s information


Additional information we should consider

Please use this space for any additional comments you may have.