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Medicare Part D Forms

Online Request for Medicare Part D Prescription Drug Coverage Determination

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

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in SPANISH

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 02/06/2018
H5992_2014_109 Approved 01/13/2014