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DSNP Coverage Determination/Appeals

DSNP Coverage Determination/Appeals

Use this form to send a request for a Part D drug directly to the Pharmacy Department.

When we receive your request, we’ll contact your provider to get the necessary information. *Indicates a required field.

Member Information
Are You the Member? *
Requestor Information

Complete the Following Section. All fields are required.

Medication Information
Prescribing Provider's Information

Personal information provided to MCC of AZ (HMO SNP) through the online determination or redetermination request forms will only be used for the requested service. It will not be shared or used for any other purpose.