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Redetermination Request

Request for Redetermination of Medicare Prescription Drug Denial For Health Partners Medicare members

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.

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.

* Required fields

Enrollee's Information

(ex: 04/13/1972)

(ex: 123456789*01)

(ex: 215-321-4567)

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

Prescription drug you are requesting

(ex: 06/10/2014)

Prescriber's Information

(ex: 215-321-4567)

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.

Please explain your reasons for appealing.