Request for Redetermination of Medicare Prescription Drug Denial

 

Because we 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.

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Expedited appeal requests can be made by phone at (888) 665-1328. �����������������������

 

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.

 

 

Enrollee�s Information

Enrollee�s Name           Date of Birth

Enrollee�s Address    

City� State �Zip Code

Phone

Enrollee�s Plan ID Number

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

Requestor�s Name

Requestor�s Relationship to Enrollee

Address

City� State Zip Code

Phone

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

Attach documentation showing the authority to represent the enrollee (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

 

Name� ������������������������������������������������������

 

Address

 

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.

 

 CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS

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.

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

 

 

 

 

Signature of person requesting the appeal (the enrollee, or the enrollee�s prescriber or representative):

 

Date:

 

 

 

 
 
 

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