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RXM1208 H3359 Member CD Request Form 2014finalversion Accessible PDF 2026
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- Click ‘Get Form’ to open the RXM1208 H3359 Member CD Request Form in the editor.
- Begin by filling out the Enrollee's Information section. Enter your name, date of birth, address, phone number, and Member ID # accurately.
- If someone other than the enrollee is making the request, complete the Requestor’s Information section with their details.
- Specify the name of the prescription drug you are requesting, including strength and quantity per month if known.
- Select the appropriate Type of Coverage Determination Request by checking the relevant boxes that apply to your situation.
- If applicable, provide additional information or attach supporting documents that may assist in processing your request.
- Sign and date the form at the bottom to confirm your request before submitting it via mail or fax as indicated.
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