Request for Redetermination of Medicare Prescription Drug Denial
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.
appeal requests can be made by phone at (866) 856-8699.
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
Fields marked with yellow background are mandatory fields.
Note: Expedited Decisions
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.
CHECK THIS BOX
IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS
you have a supporting statement from your prescriber, attach it to this
(**Attachments not available in the online form, refer to PDF form)
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.
of person requesting the appeal (the enrollee, or the enrollee’s prescriber