Superior HealthPlan DME Preferred Provider Opt-Out Request

This request form is valid for one year from the date of submission. Members may submit an opt-out form annually if they would like to continue to opt-out of the DME preferred provider program.

I, (below named), would like to opt out of the Superior HealthPlan Durable Medical Equipment (DME) preferred provider program. I would like FIFTY 50 Pharmacy to provide the DME items that are being requested on my behalf. I understand that medical supplies ordered from non-preferred DME providers will require prior authorization based on a review for medical necessity.

JDRF and FIFTY 50 Funding Diabetes Cure
Enjoy Early Notice of our Special Offers!
When you sign up for our Emails.
Your Information will never be shared with any third party.