Request for Medicare Prescription Drug Coverage Determination

Enrollee Information (Step 1 of 6)

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Welcome to the Providence Request for Medicare Prescription Drug Coverage Form.

Enrollee Information

*Enrollee Name:

*Date of Birth
(MM/DD/YYYY):

*Enrollee Member ID:

Prescriber's Information

*Prescriber Name:

*Prescriber Phone Number
(###)###-####:

User Information

*Who are you?

*Phone Number
(###)###-####:

Email Address:

Address:

Fax
(###)###-####:

NOTE: You must provide documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form or a written equivalent). One of these documents is required in order to process this request. If an electronic version is not available, please contact the Pharmacy Team at (503) 574-7400 or 1-877-216-3644 or fax to (503) 574-8646 or 1-800-249-7714.

*Requestor Name:

*Relationship to Enrollee:

*Requestor's Phone Number
(###)###-####:

Requestor's Email Address:

Providence Medicare Advantage Plans is an HMO, HMO‐POS and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

H9047_PHAAM20

Webpage is current as of 1/1/2021