CoverageRedetermination

Please complete one form per Medicare Prescription Drug you are requesting a Coverage Redetermination for.

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.

This form may also be sent to us by mail or fax:

Address:

Johns Hopkins Advantage MD
c/o CVS Caremark Part D Services
Coverage Determination and Appeals Department
PO BOX 52000 MC 109
Phoenix AZ 85072-2000

Fax: 1-855-633-7673

You may also give us a call at 1-877-293-5325 for PPO or 1-877-293-4998 for HMO (TTY:711), 24 hours a day, 7 days a week, or visit https://www.hopkinsmedicare.com/ for more information.

For questions regarding the coverage determination process, please call the customer support number on your prescription card.

Enrollee's Information

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee's First Name *

Enrollee's Last Name *

Enrollee's Phone Number *

Date of Birth

Enrollee's Street Address

City

State

ZIP Code

Enrollee ID

* Indicates required information.

Requestor Information (if not Enrollee - Prescriber, Family Member or Friend)

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

Requestor's First Name

Requestor's Last Name

Relationship to Enrollee **

Requestor's Phone Number

Street Address

City

State

ZIP Code

** Representation documentation for 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 Representative Form CMS -1696 or a written equivalent). 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?

YesNo

If "Yes": Date purchased:

Name and telephone number of pharmacy:

If "Yes": Amount paid: $ (attach copy of receipt below)

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)

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.

Prescriber Information

First Name

Last Name

Phone Number

Fax Number

Street Address

City

State

ZIP Code

NPI #

Attachments (JPG, PDF, or TIF up to 10 megabytes)

You can submit up to five (5) attachments as supporting documentation. Limit 10 megabytes allowed per prescription drug coverage determination request. If you have other drugs you would like to request a coverage determination request for, please submit a form for each. To save your document into a .jpg or a .tif, go to file, save as, and save it with the extension of your choice. If you are scanning in a document, it is possible your scanner will save it in a .pdf format.

Medicare Coverage Redetermination Form

Enrollee's Information

Requestor Information (if not Enrollee - Prescriber, Family Member or Friend)

Prescription drug you are requesting:

Important Note: Expedited Decisions

Prescriber Information

Attachments (JPG, PDF, or TIF up to 10 megabytes)