Request For Medicare Prescription Drug Coverage Determination Form

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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
This form may be sent to us by mail or fax:
Address:
Fax Number:
Blue Cross MedicareRx (PDP)℠
1-800-693-6703
Attn: Clinical Review Department
1305 Corporate Center Dr, Bldg N10
Eagan, MN 55121
You may also ask us for a coverage determination by phone at Toll Free:
1-888-285-2249
TTY/TDD: 711. We are open 8 a.m. – 8 p.m., local time, 7 days a week. If you are calling from
February 15 through September 30, alternate technologies (for example, voicemail) will be used on
weekends and holidays, 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 # __________________________
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:
Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services
Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A
Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal.
Y0096_APG_PDPCDReqForm16

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