Request for Redetermination of Medicare Prescription Drug Denial


For Leon Medical Centers Health Plans members
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.

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
First Name: *
Last Name: *
Date of Birth:   (ex. 04/13/1972)
Plan ID Number:   (ex. 123456789*01)
Street Address:
City:
State:
Zip:
Enrollee Phone:


Complete the following section ONLY if the person making this request is not enrollee:
Requestor Name:
Relashionship to Enrollee
Street Address:
City:
State:
Zip:
Requestor Phone:

Note: You will need to mail or fax separately the documentation showing the authority to represent the Enrollee (a competed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointment a representative, contact our plan or 1-800-Medicare

Prescription Drug you are requesting:
Name of drug:
Strength:
Quantity:
Dosage:
Have you purchased the drug pending appeal?
If "Yes"
Date Purchased   (ex. 04/13/1972)
Amount Paid:
Name and telephone number of pharmacy:

Prescriber's Information
Prescriber Name:
Street Address:
City:
State:
Zip:
Office Phone:
Office Fax:
Office Contact Person
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 heath, 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

Please explain your reasons for appeling. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage
You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage
Reasons for Appeal