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Request For Medicare Prescription Drug Coverage Determination Form - Blue Shield Of California

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

This form cannot be used to request barbiturates, benzodiazepines, 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)

This form may be sent to us by mail or fax:

Address:

Fax Number:

Blue Shield of California

1-888-697-8122

P.O. Box 7168

San Francisco, CA 94120

You may also ask us for a coverage determination by phone at 1-800-535-9481 or through our

website at

Who May Make a Request: Your prescriber may ask us for a coverage determination on your

behalf. If you want another individual (such as a family member or friend) to make a request for

you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee’s Information

Enrollee’s Name _____________________________________

Date of Birth _______________

Enrollee’s Address _______________________________________________________________

City ___________________________ State______________ Zip Code ___________________

Phone ______________Enrollee’s Member ID # _________Enrollee’s Medicare ID #___________

Complete the following section ONLY if the person making this request is not the enrollee

or prescriber:

Requestor’s Name _______________________________________________________________

Requestor’s Relationship to Enrollee _________________________________________________

Address _______________________________________________________________________

City __________________________________ State ________ Zip Code _________________

Phone _____________________________

Representation documentation for requests made by someone other than enrollee or the

enrollee’s prescriber:

Attach documentation showing the authority to represent the enrollee (a completed

Authorization of Representation Form CMS-1696 or a written equivalent). For more

information on appointing a representative, contact your plan or 1-800-Medicare.

H0504_12_416B CMS Approved 12312012

S2468_12_416B CMS Approved 12312012

Blue Shield of California

50 Beale Street, San Francisco,

CA 94105

Request For Medicare Prescription Drug Coverage Determination Form - Blue Shield Of California