Please complete for all Medicare Prescription Drugs 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:

Appeal Department
PO Box 52000
MC109
Phoenix, AZ 85072-2000

Fax: 1-855-633-7673

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

Enrollee's Information

 
 
 
(mm/dd/yyyy)  

* Indicates required information.

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

Who may make a request: You can fill out and submit this request yourself, or your prescriber may ask us for a coverage redetermination 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 designated as your representative. Contact us to learn how to name a representative.
Call Customer Service at 1-866-412-5393 (TTY users call 1-866-236-1069). You can call 24 hrs. daily, Central and Mountain Times.

Complete the following section ONLY if the person making this request is NOT the enrollee:
** 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 (1-800-633-4227), 24 hrs. a day, 7 days a week. TTY users call 1-877-486-2048.

Prescription drug 1 you are requesting:

Have you purchased the drug pending appeal?
 

Prescription drug 2 you are requesting:

Have you purchased the drug pending appeal?
 

Prescription drug 3 you are requesting:

Have you purchased the drug pending appeal?
 

Important Note: Expedited Decisions Must Have Prescriber’s Supporting Statement

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.
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

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.