Because we denied your request for coverage of (or payment for) a presciption 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. This form may be sent to us by mail or fax.

Expedited appeal requests can be made by telephone.

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:				Enrollee's Birthday:
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

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.  

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)
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 hour. 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. Attachments may be mailed or faxed.

DO YOU BELIEVE THAT YOU NEED A DECISION WITHIN 72 HOURS?      Yes     No

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

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 and have your prescriber address the Plan’s coverage criteria, if available, as stated in the Plan’s denial letter or in other Plan documents. Input from your prescriber will be needed to explain why you cannot meet the Plan’s coverage criteria and/or why the drugs required by the Plan are not medically appropriate for you.

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