Health Professionals
Coverage Determination Request Form

Health Professionals

MSO of Puerto Rico, Inc.
InfoMed
Office Advantage
InnovaMD
MSV Notification
Clinical Guidelines
Medicare Part D Coverage Determination Request Form

Medicare Part D Coverage Determination Request Form

This form cannot be used to request:

Medicare non covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

Biotech or other speciality drugs for which drug-specific forms are required.

Medicare Part D Coverage Determination Request Form

Listing of Provider and Pharmecy Directory documents available for download

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