• 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 be sent to us by mail or fax:






  • You may also ask us for an appeal through our website at . Expedited appeal requests can be made by phone at (866)567-7242.
  • 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
    • Representation 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 the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.
    • Name of prescription drug you are requesting:
    • (attach copy of receipt)
  • Prescriber's Information
    • Attachments are optional. If needed you can upload and attach files to this request.
      The following file extensions are allowed: ".pdf, .doc, .docx, .xls, .xlsx, .ppt, .txt"
      Files must be 3 MB (3,000,000 bytes) or less.

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    • 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 you 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.
    • Signature of person requesting the appeal (the enrollee, or the enrollee's prescriber or representative):
  • H2419, H5703_4170_C