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, call 1-855-364-0974, hearing impaired (TTY: 711). We are available 24 hours a day, 7 days a week.

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

Fax
Part D Coverage Determinations 
Pharmacy Department
1-855-365-8108

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. Your prescriber can call 1-855-364-0974, Monday through Friday 8 a.m. to 7 p.m. EST. 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.