Submit a Coverage Determination Request 

Please complete the form on this page and select “Submit” to make your request. All fields are required unless they say “optional.” We will send your information securely to protect your privacy. If you’d like to print a copy for your records, use your web browser’s “print” function.  

Note: Some requests may need a supporting statement from your prescriber. 

If you’d prefer to complete this form by hand, download a PDF of the Coverage Determination Request Form. Then follow the instructions on the form to return it by mail or fax.