Please complete one form per Medicare Prescription Drug you are requesting a Coverage Determination for.
Because we, Blue MedicareRx (PDP), 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.
This form may also be sent to us by mail or fax:
P.O. Box 52000
Phoenix, AZ 85072-2000
Fax Number: 1-855-633-7673
You may also ask us for a coverage determination by phone 24 hours a day, 7 days a week by calling the
telephone number on the back of your Blue MedicareRx id card.