How can I join?
Call the New York Enrollment Broker:
1-855-600-FIDA (Toll-free)
TTY/TDD 1-888-329-1541
Participant Services:
1-844-861-FIDA (3432), TTY/TDD: 711

Medicare-Medicaid Prescription Forms


Online Request for Prescription Drug Coverage Determination

Download the Drug Coverage Determination Form (PDF) in ENGLISH.

Download the Drug Coverage Determination Form (PDF) in SPANISH.

Download the Drug Coverage Determination Form (PDF) in CHINESE.


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 Redetermination


Last Updated 2/06/2018
H8851_2015_099 Approved 12/18/2014