Coverage Determination Form

Coverage Determination Form

Fill out the Coverage Determination Form online. Alternatively, you can download or request a paper copy of this form and send it us by mail or fax.

For questions or to request a paper copy, just call Member Services toll-free at 1-855-676-5772 (TTY 711). We are available 24 hours a day, 7 days a week.

Mail:
Aetna Better Health of Michigan
Part D Coverage Determination
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Fax:
MED D Clinical Operations
Coverage Determinations
Fax: 1-844-242-0914

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. Your prescriber can call toll-free at 1-855-676-5772 (TTY 711). We are available 24 hours a day, 7 days a week. 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.