Fillable Request for Reconsideration of Medicare Prescription Drug Denial/At-Risk (Medicare Part D Appeals)

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Request for Reconsideration of Medicare Prescription Drug Denial/At-Risk (Medicare Part D Appeals)

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Request for Reconsideration of Medicare Prescription Drug Denial/At-Risk Determination
Because your Medicare drug plan has upheld its initial decision to deny coverage of, or payment for a
prescription drug you requested, or upheld its decision regarding an at-risk determination made under its drug
management program, you have the right to ask for an independent review of the plan’s decision. You may
use this form to request an independent review of your drug plan’s decision. You have 60 days from
the date of the plan’s Redetermination Notice to ask for an independent review. Please complete this form and
mail or fax it to:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 703
Pittsford, NY 14534-1302
Toll Free Fax: (866) 825-9507
Fax for Enrollees: (720) 462-7575
Note about Representatives: Your prescriber may file a reconsideration request on your behalf without
being an appointed representative. If you want another individual, such as a family member or friend to
request an independent review for you, that individual must be appointed as your representative.
E
nrollee Information:
E
nrollee Name: _
Address:
City: State: Zip Code:
Phone: ( )
Medicare Beneficiary Identifier #:
(From red, white and blue Medicare card)
Date of Birth (MM/DD/YYYY):
Name of current Part D Drug Plan:
Representative’s Name:
Complete the following section ONLY if the person making this request is not the enrollee or the enrollee’s
prescriber (make sure to attach documentation showing the person’s authority to represent enrollee for
purposes of this request):
Representative’s Relationship to Enrollee:
Address:
City: State: Zip Code:
Phone: ( )
Prescription drug you asked your plan to cover:
MAXIMUS Federal Services
Medicare Part D QIC Reconsideration Project
V3.3
Representation documentation for appeal request made by someone other than enrollee or
p rescriber:
Attach documentation showing the authority to represent the enrollee (a completed Form CMS-1696
or a written equivalent) if it was not submitted at the coverage determination or redetermination
level. A physician or other prescriber may request an appeal on behalf of the enrollee without being an
appointed representative.
PPres
cribing Physician’s or Other Prescriber’s Information:
Prescriber Name:
City: State: Zip Code:
Office Phone: ( )
Office Fax: ( )
Office Contact Person:
Off
ice Address:
Expedited Decisions
If you or your
prescribing physician or other
prescriber
believe that waiting for a standard decision (which will be
provided
within 7 days) could
seriously harm your
life,
health,
or
ability
to regain maximum
function,
you can
ask
for an expedited (fast) decision.
If
your
prescribing
physician or other
prescriber indicates
that
waiting 7
days
could seriously
harm
your
life or
health or ability
to regain maximum
function,
the independent
review
organization
will automatically
give you a decision within 72 hours.
This
timeframe may
be extended for
up
to 14 calendar
days
if
your
case involves
an exception
request
and
we
have not
received the supporting
statement from your
doctor
or other
prescriber supporting
the request,
OR the person acting for you
files
an
appeal
request
but
does
not
submit
proper
documentation
of representation.
If
you
do not
obtain your
physician’s or other
prescriber's
support
for an expedited appeal,
the independent
review organization will
decide
if
your
health
condition
requires
a
fast
decision.
C
heck this box if you believe you need a decision within 72 hours (if you have a supporting statement
from your prescribing physician or other prescriber, attach it to this request)
P
P
lease
attach any
additional
information you have related to your
appeal such as
a statement
from
your
prescribing physician or
other
prescriber
and
relevant
medical
records.
Please have
your
prescriber
address
the
Plan’s
coverage criteria
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.
A
dditional information we should consider:
Important: Please include a copy of the Redetermination (denial) Notice that you should have received
from your drug plan if available.
Signature of person requesting the appeal (the enrollee or the representative):
D
ate:
MAXIMUS Federal Services
Medicare Part D QIC Reconsideration Project
V3.3
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Request for Reconsideration of Medicare Prescription Drug DenialAt-Risk (Medicare Part D Appeals)

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Completed 31 January 2021

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