How to Make an Appeal
If you would like to appeal a coverage decision we made about a prescription drug, you, your doctor, or your representative must contact Member Services. If you are asking for a standard appeal, make your standard appeal in writing by submitting a signed request to us. In your request, please include your name, member ID (from your ID card), your address and phone number, the prescription drug you want to appeal and why you disagree with coverage decision we made. You can also download the Request for Redetermination of Medicare Prescription Drug Denial form, print a copy, complete and mail it to the address on the form or fax it to the number on the form. You can also call Member Services to make your appeal.
If you have someone appealing our decision for you other than your doctor, you appeal must include an Appointment of Representative form authorizing this person to represent you.
If we use the standard deadlines for your appeal, we must give you our answer within seven calendar days after we receive your appeal if your appeal is about a prescription drug you have not received yet.
If your health requires it, ask for a “fast appeal.” If your doctor tells us that your health requires a “fast appeal,” we will automatically agree to give you a fast appeal. If you ask for a “fast appeal” on your own, without a doctor’s support, we will decide whether your health requires that we give you a fast decision, which we make within 72 hours after we receive your appeal. If we decide that your medical condition does not meet the requirements for a “fast appeal,” we will send you a letter that says so and we will use the standard deadline, which is within seven calendar days for prescription drugs you have not yet received.
You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you have a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
You can ask us for a copy of the information regarding your coverage decision and add more information to support your appeal.
If our answer is “yes” to part or all of what you requested, we must provide the coverage we have agreed to provide within seven calendar days after we receive your appeal for standard deadlines or 72 hours after we receive your appeal for “fast” deadlines. If you are asking us to pay you back for a drug you have already bought and we say “yes” to your appeal, we have to make payment to you within 30 calendar days after we receive your appeal.
If our answer is “no” to part or all of what you requested, we will send you a written statement that explains why we said “no.” You decide if you want to make another appeal. If you do, you will go onto a Level 2 Appeal and an Independent Review Organization reviews the decision we made. Instructions how to make a Level 2 appeal are included in the written notice we send to you when we said “no” to your first appeal.
For more information about making an appeal and Levels 2, 3, 4 and 5 of the appeals process, please see Chapter 9, Sections 6 and 9 of the 2023 Evidence of Coverage, or contact Member Services. You may contact Member Services to check on the status of your appeal.