Coverage Redetermination form

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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 65 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:

Address:

Appeals Department
MC109
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.

All fields are optional unless marked required.

Enrollee's Information

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee's first name (required)

Enter a valid First Name

Enrollee's last name (required)

Enter a valid Last Name

Enrollee's phone number (required)

Enter Valid Phone Number

Date of birth

Enrollee's street address

Unit, apartment, etc

City

State

Zip Code

Enrollee's Member ID

Requestor Information (if not Enrollee - Prescriber, Family Member or Friend)

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor First Name (Optional)

Requestor Last Name (Optional)

Requestor Relationship To Beneficiary (Optional)

Phone Number (Optional)

Requestor Street Address (Optional)

City (Optional)

State (Optional)

Zip Code (Optional)

Prescription drug you are requesting:

Name of Drug

Strength/quantity/dose:

Have you purchased the drug pending appeal?

Yes

Date purchased (Optional)

Amount paid (Optional)

Important Note: Expedited Decisions

If you or your prescriber believe that waiting 7 days hours 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 request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination 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 (if you have a supporting statement from your prescriber, attach it to this request).

Please explain your reasons for appealing. Attach additional pages, if necessary. Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

Prescriber Information

First Name (Optional)

Last Name (Optional)

Phone Number (Optional)

Fax Number (Optional)

Street Address (Optional)

City (Optional)

State (Optional)

ZipCode (Optional)

Prescriber Npi Number (Optional)

Attachments (JPG, PDF, or TIF up to 3 megabytes)

Attachments (JPG, PDF, or TIF up to 3 megabytes) You can submit up to five (5) attachments as supporting documentation. Limit 3 megabytes allowed per prescription drug coverage determination request. If you have other drugs you would like to request a coverage determination request for, please submit a form for each. To save your document into a .jpg or a .tif, go to file, save as, and save it with the extension of your choice. If you are scanning in a document, it is possible your scanner will save it in a .pdf format.

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