Request Appeal for Drug Coverage

Enrollee's Information

First Name

Last Name

ID Number

Date of Birth

Enrollee's Contact Information

Email Address

Phone Number

Street Address

Zip Code

City

State

Requestor's Contact Information

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

First Name

Last Name

Relationship to Enrollee

Phone Number

Street Address

Zip Code

City

State

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) and enter a brief explanation below.

Prescription Drug Information

Name of Drug and Strength

Quantity Requested per Month

Dose

Check if you purchased the drug pending appeal

If "Yes":

Date Purchased

Amount Paid & Attach Receipt

Pharmacy Name

Pharmacy Phone Number

Prescriber's Information

First Name

Last Name

Street Address

Zip Code

City

State

Phone Number

Fax Number

Important Notes: Expedited Decision 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. Enter 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, the enrollee's prescriber, or representative) and date are required upon submission.

Signature

Date

Request Appeal for Drug Coverage

Please correct the following errors:

Please correct the following errors

Enrollee's Information

Enrollee's Contact Information

Requestor's Contact Information

Prescription Drug Information

Prescriber's Information

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Request Appeal for Drug Coverage

Please correct the following errors:

Please correct the following errors

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Information

Prescriber's Information

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Enrollee's Information

Requestor's Contact Information