Request for Redetermination of Medicare Prescription Drug Coverage

Understanding Your Request Options

You are about to fill out an online form requesting redetermination of Medicare prescription drug coverage.

Because we denied your request for coverage (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 for a redetermination.

You can submit your request for redetermination in two ways:

Use Online Form

Continue with Online Request

Fill out the request form here and submit it digitally. If additional information is required, we will contact your doctor.

Or

Print, Mail or Fax

Print & Complete a Hard Copy

Print the entire request form now. Fill out your information and mail the completed hard copy to us directly.