Request a Redetermination

REQUEST FOR REDETERMINATION OF MEDICARE PRESCRIPTION DRUG DENIAL

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.

This form may be sent to us by mail or fax:

Address:
P.O. Box 151926
Tampa, FL 33684 Fax Number:
1-813-490-5338

You may also ask us for a coverage Redetermination by phone at 1-833-272-9772 or through our website at https://www.freedomhealth.com/medicare/pharmacy_and_part_d/ .

"Asterisk mark (*) denotes it is a mandatory field and shouldn't be left blank"

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.

Enrollment Information

Enrollee's Name

Date of Birth

Enrollee's Address

City

State

Zip Code

Phone

Enrollee's Member ID#

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

Requestor's Name

Requestor's Relationship to Enrollee

Address

City

State

Zip Code

Phone

Representation documentation for appeal requests made by someone other than the enrollee or the enrollee's prescriber:

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-MEDICARE.

Prescription Drug you are requesting

Name of Drug

Strength/Quantity/Dose

Have you purchased the drug pending appeal? Yes No

If "Yes"
Date Purchased

Amount Paid: $
(attach copy of receipt)

Pharmacy Name

Pharmacy Phone

Prescriber's Information

Prescriber's Name

Address

City

State

Zip Code

Office Phone

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 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 reason 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 and have your prescriber address the Plan's coverage criteria, if available, as stated in the Plan's denial letter or in other Plan documents. Input from your prescriber will be needed to explain why you cannot meet the Plan's coverage criteria and/or why the drugs required by the Plan are not medically appropriate for you.

Attach your items here:

Documents

Signature of person requesting the appeal (the enrollee, or the enrollee’s prescriber or the representative):

Signature:

Date:

H5427_Redetermination Form_C

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