RXM1208 H3359 Member CD Request Form 2014finalversion Accessible PDF 2026

1. Click ‘Get Form’ to open the RXM1208 H3359 Member CD Request Form in the editor.
2. Begin by filling out the Enrollee's Information section. Enter your name, date of birth, address, phone number, and Member ID # accurately.
3. If someone other than the enrollee is making the request, complete the Requestor’s Information section with their details.
4. Specify the name of the prescription drug you are requesting, including strength and quantity per month if known.
5. Select the appropriate Type of Coverage Determination Request by checking the relevant boxes that apply to your situation.
6. If applicable, provide additional information or attach supporting documents that may assist in processing your request.
7. 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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