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

Listado de documentos de Cambios al Formulario

How to download documents

These documents are in Adobe PDF format. Adobe Acrobat Reader is needed to be able to open and read these documents. If you don't have Adobe Acrobat Reader, you may download it for free by clicking here (link will open on a new window).