* Required fields

Enrollee's Information

First Name *

Last Name *

Date of Birth
(ex: 04/13/1972)
Plan ID Number
(ex: 123456789*01)
Address

Address 2

City

State *
(please 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 Missouri Montana 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 Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip *

Telephone *
(ex: 215-321-4567)

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

Requestor Name

Relationship to Enrollee

Address

Address 2

City

State

Zip

Telephone

Note: You will need to mail or fax separately the 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.

Prescription drug you are requesting

Name of drug

Strength

Quantity

Dosage

Have you purchased the drug pending appeal?
Yes
No

If "Yes":
Date Purchased
(ex: 06/10/2014)
Amount Paid ($)

Name and Telephone number of Pharmacy

Prescriber's Information

Prescriber Name

Address

Address 2

City

State

Zip

Office Telephone
(ex: 215-321-4567)
Office 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 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.

Please explain your reasons for appealing. 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.

You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

Reasons for Appeal *