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Medicare PartD Coverage Determination Request Form

Request FOR Medicare PRESCRIPTION DRUG Coverage Determination This form may be sent to us by mail or fax: Address: OptumRx Fax Number: 1-844-403-1028 Prior Authorization Department Box 25183 Santa Ana, CA 92799 You may also ask us for a Coverage Determination by calling the member services number on the back of your ID card. 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.

☐ I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).* ... Would a lower total daily MED dose be insufficient to control the enrollee’s pain? ...

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