Request for Redetermination of Medicare Prescription Drug Denial


Because we Molina Dual Options Medicare-Medicaid Plan denied your request for coverage of (or payment for) a prescription drug, 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.


Expedited appeal requests can be made by phone at (855) 735-5831.                        


Who May Make a Request:  Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.


Fields marked with yellow background are mandatory fields.


Member’s Information

Member’s Name           Date of Birth

Member’s Address    

City  State  Zip Code


Member’s Plan ID Number  

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

Requestor’s Name

Requestor’s Relationship to Member


City  State Zip Code


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

Attach documentation showing the authority to represent the member (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level.  For more information on appointing a representative, contact your plan or 1-800-Medicare.

(**Attachments not available in the online form, refer to PDF form)

Prescription drug you are requesting: 


Name of drug:  Strength/quantity/dose: 


Have you purchased the drug pending appeal?   Yes No


If “Yes”:

Date purchased: Amount paid:  $ (attach copy of receipt)       

(**Attachments not available in the online form, refer to PDF form)

Name and telephone number of pharmacy:          


Prescriber's Information






City   State    Zip Code


Office Phone Fax


Office Contact Person



Important Note:  Expedited Decisions

If you or your prescriber believe 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.



If you have a supporting statement from your prescriber, attach it to this request.

(**Attachments not available in the online form, refer to PDF form)


Please explain your reasons for appealing.  Attach additional pages, if necessary.  Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records.  You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.





Signature of person requesting the appeal (the member, or the member’s prescriber or representative):







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