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Medicare Part D Forms

Online Request for Medicare Part D Prescription Drug Coverage Determination

Download the Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in ENGLISH.

If you are interested in filing an appeal of a denial of medications, please complete the applicable form below or have your physician complete the form.

Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF).

Online Request for Medicare Part D Redetermination


Last Updated 2/08/2018
H2224_2014_122 Approved 01/13/2014