Request for Redetermination of Medicare Prescription Drug Denial

If denies to cover or pay for a prescription drug, you or your representative can ask us to review our decision. This is called a redetermination or an appeal. Use this form to send us your appeal.

When we denied your drug, you received a Notice of Denial of Medicare Prescription Drug Coverage. You have 60 days from the date on that notice to send us your appeal.

Who may request an appeal

You may ask us for an appeal. The provider who prescribed your drug — your prescriber — may also ask us for an appeal on your behalf. If you want someone else to request an appeal for you, such as a family member or friend, they must be your representative. Contact us to learn how to name a representative.

Important note: expedited decisions

You or your prescriber can ask for an expedited (fast) decision if you believe that waiting 7 days for a standard decision could seriously harm your:

Life.
Health.
Ability to regain maximum function.

If your prescriber tells us that waiting 7 days could seriously harm your health, we will give you a decision within 72 hours (3 days). If you do not get 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 got.

Check this box if you need a decision within 72 hours.
You can also call to request an expedited appeal.

Enrollee's information

* Required field

Enrollee's name: *

Date of birth: *
- -

Enrollee's address: *

City: *
State: *

ZIP code: *

Phone: *

Enrollee's Member ID number: *

Check if completed by someone other than the enrollee

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

Requestor's name: *

Requestor's relationship to enrollee: *

Requestor's address: *

City: *
State: *

ZIP code: *

Phone: *

Prescription drug you are requesting

* Required field

Name of drug: *

Strength/quantity/dose: *

Did you already purchase the drug in your appeal? (optional)

No
Yes

If “Yes”:

Date purchased: *
- -

Amount paid: *

Name of pharmacy: *

Pharmacy phone number: *

Prescriber's information

* Required field

Prescriber's Name: *

Prescriber's Address: *

City: *
State: *

ZIP code: *

Office phone: *

Fax:

Office contact person:

Reasons for appealing

* Required field

Please explain why you are appealing. Include 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

You can fax or mail to us any documents that support your request, such as:

Authorization of Representation.
Supporting statements from your prescriber.
Relevant medical records.
A copy of your receipt if you already paid for the drug.

Send by fax: 1-855-221-0046

Send by mail:

Attention: Appeals and Grievances department

P.O. Box 80109
London, KY 40742-0109