Prescription Drug Appeals (Coverage Redetermination)

Part D Appeals

Because we, Virginia Premier CompleteCare (Medicare-Medicaid Plan), a Commonwealth Coordinated Care Plan, 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.

Note: All fields marked with an asterisk (*) are required.

Person Making Request*

Member
Prescribing Provider
Other Representative

Enrollee's Name*

First Last

Date of Birth*

Enrollee's Address*

Street Address Address Line 2 City State ZIP Code

Phone

Enrollee's Member ID #*

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

Requestor's Name

First Last

Requestor's Relationship to Enrollee

Requestor's Address

Street Address Address Line 2 City State ZIP Code

Requestor's Phone

Representation documentation for requests made by someone other than 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.

Authorization of Representation Form CMS-1696

Download Drug Coverage Redetermination form (pdf)

Prescription drug you are requesting:

Name of Drug:*

Strength / quantity / dose:

Have you purchased the drug pending appeal?*

Yes
No

If "Yes", Date Purchased:*

Amount paid: $$

Please attach copy of receipt.

Copy of Receipt

Name of Pharmacy:

Phone Number of Pharmacy:

Prescriber's Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

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.

Expedited appeal requests can be made by phone at 1-855-338-6467.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS

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.

Please attach document

Signature of person requesting the appeal (the enrollee or representative, or the enrollee's prescriber:*

I am electronically signing this form by typing my name above.

Members

Prescription Drug Appeals (Coverage Redetermination)

Request for Redetermination of Prescription Drug Coverage

Step 1 of 2

Part D Appeals

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

Representation documentation for requests made by someone other than enrollee or the enrollee’s prescriber:

Prescription drug you are requesting:

Prescriber's Information

Important Note: Expedited Decisions

Confirmation Summary