Request for Redetermination of Medicare Prescription Drug Denial

Enrollee's name (required)

Date of birth (required) MMDDYYYY

Street address

Unit, apartment, etc.

City

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ZIP Code

Phone required Enter 10-digit phone number

Enrollee's Member ID#

Requestor's Name

Requester's relationship to enrollee¹

Street Address

Unit, apartment, etc

City

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ZIP Code

Phone Number Enter 10-digit phone number

Name of Drug

Strength/Quantity/Dose

Have you purchased the drug pending appeal?

Yes

No

If "Yes", Date purchased MMDDYYYY

Name and telephone of pharmacy

If 'yes', amount paid (attach copy of receipt below)

Prescriber's name

Street Address

Unit, apartment, etc

City

State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Missouri Massachusetts Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming

ZIP Code

Office Phone Enter 10-digit phone number

Fax

NPI #

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 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.

An electronic signature is required on this request.

Clicking the submit button at the bottom of this form, will serve as your electronic signature.

Signature

Date MMDDYYYY