Online Redetermination Request

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

If 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 at 1-866-901-8000 (TTY 1-877-454-8477) to learn how to name a representative.

Enrollee Information

First Name *

Last Name *

Date of Birth

Plan ID Number

Address *

Address 2

City *

State

New Jersey

Pennsylvania

ZIP Code *

Phone *

Is the person making this request the Enrollee?

Yes

Requester Information

Your Name *

Your relationship to the Enrollee *

Your Address *

Your Address (Line 2)

Your City *

Your State *

New Jersey

Pennsylvania

Your ZIP Code *

Your 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

Date Purchased

Amount Paid ($)

Name and Phone Number of Pharmacy

Prescriber Name

Address

Address 2

City

State

ZIP Code

Office Phone

Office Fax

Office Contact Person

Reasons for Appeal

Please tell us why this request should be approved. *

Important Note: 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