Enrollee’s Name
Date of Birth (dd/mm/yyyy)
Enrollee’s Address
City
State
Zip Code
Phone
Enrollee’s Member ID Number

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

Requestor’s Name
Requestor’s Relationship to Enrollee
Enrollee’s Address
City
State
Zip Code
Phone

Prescription drug you are requesting:

Name of drug
Strength/quantity/dose
Have you purchased the drug pending appeal? YesNo
If “Yes”:
Date purchased
Amount paid
Name and telephone number of pharmacy

Prescriber's Information

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 appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

I 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.

Δ