Request for Redetermination of Medicare Prescription Drug Denial

Please use this form to request a Medicare prescription drug coverage re-determination. You may also ask us for a coverage re-determination by phone at 1-888-786-7509.

Please correct the items below.

1. Enrollee's information

Please enter an enrollee's member ID #.
Please enter an enrollee's first name.
Please enter a middle initial.
Please enter a last name.
Date of birth month is required.
Please enter a day.
Please enter a year.

Date of birth

Please enter a street address.
Please enter a city.
Please select a state.
Please enter a ZIP.
Please enter a telephone number.

Please tell us who you are:

This information is required.

* The enrollee's prescriber may ask Moda Health for a coverage determination on his/her behalf.

** If the enrollee would like another individual (such as a family member or friend) to make a request for on his/her behalf, that individual must be the enrollee's authorized representative. Please contact us to learn how to designate an authorized representative.

Authorized representative's information

You have indicated that you are not the enrollee or prescriber. Please complete the following information:

Please enter a representative's first name.
Please enter a middle initial.
Please enter a last name.
Please enter relationship to enrollee.
Please enter a street address.
Please enter a city.
State is required.
Please enter a ZIP.
Please enter a telephone number.

Upload authorized representative form

Please attach documentation establishing your authority to represent the enrollee (a complete authorization form CMS-1696 or a written equivalent).

For more information on appointing a representative, please contact Moda Health or call 1-800-MEDICARE.

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2. Prescription drug request

Please enter your requested medication below:

Please enter medication name.
Please enter strength.
Please enter quantity.
Please enter dose.
This information is required.

Have you purchased this drug pending appeal?

Please enter a pharmacy name.
Please enter a pharmacy telephone number.
Month is required.
Please enter a day.
Please enter a year.
Please enter an amount paid.
$

Please attach a copy of your receipt:

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3. Prescriber's information

Please enter a prescriber's first name.
Please enter a last name.
Please enter a street address.
Please enter a city.
Please select a state.
Please enter a ZIP.
Please enter office telephone.
Please enter office fax.

4.

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.

Do you need a decision in 72 hours?

This information is required.

If you have a supporting statement from your prescriber, please attach it to this request.

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5.

Please explain your reason(s) for appealing. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

This information is required.

Please attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records.

If you have a supporting statement from your prescriber, please attach it to this request.

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6. Confirm your request

  • Enrollee:
  • Medication name:
  • Strength/dosage:
  • Quantity:
  • Prescriber:
  • Reason for appealing:
  • Request for expedited decision:

Please sign and date below

Please enter name.