Samaritan Health Plan Operations
Request for Medicare Prescription Drug Coverage Determination
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 and already have documentation on file. Documentation to represent the enrollee (Authorization of Representation Form CMS-1696 or written equivalent) can be submitted via mail, fax or in person.
* required field
Enrollee's Information
First Name: * Last Name: *
Member ID:*   Date of Birth: *
Address: *
City: * State: * Zip: *
Phone:*