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.