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:
P.O. Box 151926
Tampa, FL 33684
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.
Complete the following section ONLY if the person making this request is not the enrollee or prescriber:
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
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:
Signature of person requesting the appeal (the enrollee, or the enrollee’s prescriber or the representative):