Request For Medicare Prescription Drug Coverage 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 Blue Shield of Massachusetts
1-617-246-8506
Medicare Advantage
Part D Appeals Coordinator
P.O. Box 55007
Boston, MA 02205
You may also ask us for a coverage determination by phone at 1-800-200-4255 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:
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.
Name of prescription drug you are requesting (if known, include strength and quantity
requested per month):
Y0014_11308 R1 CMS Approved 02162012

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