Coverage Determination Form

Request for Medicare prescription drug coverage determination

This form may be sent to us by mail or fax:

Mail:
Mercy Care Advantage
Part D Coverage Determination
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Fax: 1-855-230-5544

You may also ask us for a coverage determination by phone at 602-586-1730 or 1-877-436-5288 or through our website. We are available 8:00 a.m. - 8:00 p.m., 7 days a week. TTY/TDD users should call 711.

Fill out the Coverage Determination Form online.

You can also fill out this form in Spanish.

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.