Request For Medicare Prescription Drug Coverage Determination Form printable pdf download

Request For Medicare Prescription Drug Coverage Determination Form

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

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

Address:

Fax Number:

BlueShield of Northeastern New York

(716) 887-8981

P.O. Box 80

or Toll-Free Fax 1-866-221-5784

Buffalo, NY 14204

Attn: Pharmacy

You may also ask us for a coverage determination by phone at 1-800-329-2792. TTY Users

should call 1-877-834-6918.

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.

Y0086_PTD213 CMS approved 12292011

Request For Medicare Prescription Drug Coverage Determination Form