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Request for Redetermination of Medicare Prescription Drug Denial

Since your request for coverage of (or payment for) a prescription drug was denied, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. Please complete the form below and click submit. Please note that the completion of this form does not constitute completion of the coverage redetermination process and is not a guarantee of plan coverage.

Enrollee's Information

Enrollee’s Name*:


First Name	Middle Initial	Last Name

Date of Birth*:


mm	dd	yyyy

Enrollee's Address 1*:

Enrollee's Address 2:

City*:

State*:

ZIP Code*:

Phone*:

Enrollee’s Member ID Number*:

Complete the following section ONLY if the person making this request is not the enrollee:

Requestor’s Name:


First Name	Middle Initial	Last Name

Relationship to Enrollee:

Address 1:

Address 2:

City:

State:

ZIP Code:

Phone:

Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:

You will need to provide documentation showing the authority to represent the enrollee (a completed Appointment of Representative Form CMS - 1696 or written equivalent). To access the Appointment of Representative Form CMS - 1696, visit: https://www.cms.gov/cmsforms/downloads/cms1696.pdf

Prescription drug you are requesting

Name of drug*:

Strength/Quantity/Dose*:

Have you purchased the drug pending appeal?*:

Yes

If "Yes": Date purchased


mm	dd	yyyy

Amount Paid:

Name and telephone number of pharmacy:

Prescriber’s Information

Name*:

Address 1*:

Address 2:

City*:

State*:

ZIP Code*:

Office Phone*:

Fax*:

Office Contact Person:

*Indicates required fields

Important Note: Expedited Decisions

If you or your prescriber believes that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS. If you have a supporting statement from your prescriber, please follow the supporting information instructions below.

Additional information

Please explain your reasons for appealing. Provide any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records.

Supporting information

Please send any supporting information by fax to 1.877.852.4070 and be sure to include your name and telephone number on each page sent.

Cancel Submit

Enrollee's Information
Enrollee Name:
Date of Birth:
Enrollee's Address 1:
Enrollee's Address 2:	-
City:
State:
Zip Code:	07764
Phone:	-
Enrollee's Plan ID Number:	4857238

Prescription drug you are requesting
Name of drug:
Strength/Quantity/Dose:
Have you purchased the drug pending appeal?:	Yes
Date Purchased:
Amount Paid:
Name and telephone number of pharmacy:	N/A

Enrollee's Information

Prescription drug you are requesting

Prescriber’s Information

Additional information

Supporting information

You are just about done!

Thank you for your request!

Enter email address*:
Re-enter email address*: