Providers may request a redetermination by submitting an appeal with supporting documentation.
You may file an appeal of a drug coverage decision any of the following ways:
Online: Complete our online Request for Redetermination of Medicare Prescription Drug Denial (Appeal).
Fax: Complete an appeal of coverage determination request and fax it to 1-866-388-1766.
Mail: Complete an appeal of coverage determination request and send it to:
Basis for Requests
Providers may request coverage or exception for the following:
- Drugs not listed in the Formulary
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Most self-injectable and infusion medications
- Drugs that have an age limitation
- Drugs listed on the PDL but still requiring Prior Authorization (PA)
- Brand name drugs when a generic exists
- Drugs that have a step edit (ST) and the first-line therapy is inappropriate