Request For Medicare Prescription Drug Determination Request Form(s) For Enrollees and Providers

How to Ask us to Cover a Prescription Drug

You may ask us to cover a prescription drug for you.

  • Please complete the “REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION FORM” Click Here to Download
  • Be sure to include your personal information such as your name and member number from the Brand New Day Identification card.
  • Check the box that best describes the type of coverage request you are asking for.
  • If you want to be reimbursed for a covered prescription drug that you have paid for, check that box and provide copies of proof of how much you paid.
  • You may need a supporting statement from your prescribing doctor. Your doctor may write out an explanation or complete the section of the “REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION FORM” titled “Supporting Information”.
  • Mail or fax your completed form to:Address:
    Brand New Day C/O MedImpact
    10680 Treena Street Suite 500
    San Diego, CA 92131

    Fax Number:
    858-790-7100

  • We will make a decision within 72 hours of receiving your request or 24 hours if your request was for a fast decision.
  • You may also call us at: 866-255-4795 TTY: 866-321-5955
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