Online Redetermination Request

Request for Redetermination of Medicare Prescription Drug Denial For Jefferson Health Plans Medicare members

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

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.

First Name *

Last Name *

Date of Birth

Plan ID Number

Address *

Address 2

City *

State

New Jersey

Pennsylvania

ZIP Code *

Phone *

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

Requester Name

Relationship to Requestor

Address

Address 2

City

State

New Jersey

Pennsylvania

ZIP Code

Phone

Note: You will need to mail or fax separately the documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan.

Prescription Drug You are Requesting

Name of Drug

Strength

Quantity

Dosage

Have you purchased the drug pending appeal?

Yes

If "Yes": Date Purchased

Amount Paid ($)

Name and Phone Number of Pharmacy

Prescriber's Information

Prescriber Name

Address

Address 2

City

State

ZIP Code

Office Phone

Office 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 believe I need a decision within 72 hours

Please explain your reasons for appealing. 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.

You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

Reasons for Appeal *