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.

This request can be submitted online by selecting the Submit button at the bottom of the page If you do not wish to submit the request online, this form may be sent to us by mail or fax:

• You may ask for an appeal within 65 days of the date of our Notice of Denial of Medicare Prescription Drug Coverage.
• Expedited appeal requests can be made by phone.

Your prescriber can ask for an appeal on your behalf. If you want another person (like a family member or friend) to file an appeal for you, that person must be your representative. Call us to learn how to name a representative.

Plan enrollee information

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Enrollee name:
Member ID Number:				Date of birth (MM/DD/YYYY):
Mailing address:
City, State, ZIP code:
Phone:

Prescription & prescriber information

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Name of drug you asked for:
Strength/Quantity/dose:
Prescriber name:
Office address:
City, State, ZIP code:
Office phone:				Office fax:
Office contact person:

Did you already purchase this drug?	Yes   No
If 'Yes':
Date Purchased:		Amount Paid: $		(Attach copy of receipt)
Pharmacy name:
Pharmacy phone number:

Do you need an expedited (fast) decision?

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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.  

• 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’ll automatically give you a decision within 72 hours. You can’t ask for an expedited appeal if you’re asking us to pay you back for a drug you already got.
• If you don’t get your prescriber's support for an expedited appeal, we’ll decide if your case requires a fast decision.

Explain why you think this drug should be covered

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• Attach any additional information you think may help your case, like statement from your prescriber or medical records.
• Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage
• Your prescriber will need to explain why you can’t meet our plan’s coverage rules and/or why the drugs required by the plan aren’t medically appropriate for you.
• • Other information we should consider:

Representative information

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Complete this section ONLY if the person making this request is not the enrollee or the enrollee’s prescriber. You must attach documentation showing your authority to represent the enrollee (like a completed Form CMS-1696 or a written equivalent) if it wasn’t submitted at the coverage determination level. For more information on appointing a representative, Call your plan.

Representative name:
Relationship to enrollee:
Street address:
City, State, ZIP code:
Phone:

Sign & submit this form

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