Request for Redetermination of Medicare Prescription Drug Denial

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Because we, VIVA MEDICARE, 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 65 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:

Address:

VIVA MEDICARE
Pharmacy Department
417 20th Street North
Suite 1100
Birmingham AL 35203

Fax Number:

205-449-2465

You may also ask us for an appeal through our website at www.vivahealth.com/Medicare. Expedited appeal requests can be made by phone at 1-800-294-7780 , 24 hours a day, 7 days a week.

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

All fields are optional unless marked as required.

Enrollee's name (required)

Date of birth (required) MMDDYYYY

Street address

Unit, apartment, etc.

City

State

ZIP Code

Phone required Enter 10-digit phone number

Enrollee's Member ID#

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

Requestor's Name

Requester's relationship to enrollee¹

Street Address

Unit, apartment, etc

City

State

ZIP Code

Phone Number Enter 10-digit phone number

¹Representation documentation for appeal 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 Representation Form CMS-1696 or a written equivalent) if it was not submitted at coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare, 24 hours a day, 7 days a week. TTY users call:1-877-486-2048.

Prescription Drug you are Requesting:

Name of Drug

Strength/Quantity/Dose

Have you purchased the drug pending appeal?

Yes

If "Yes", Date purchased MMDDYYYY

Name and telephone of pharmacy

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

Prescriber’s Information

Prescriber's name

Street Address

Unit, apartment, etc

City

State

ZIP Code

Office Phone Enter 10-digit phone number

Fax

NPI #

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 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

Attachments

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.

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An electronic signature is required on this request. Clicking the submit button below, will serve as your electronic signature.