Request Appeal for Drug Coverage

Enrollee's Information

First Name

Last Name

ID Number

Date of Birth

Enrollee's Contact Information

Dirección de correo electrónico

Phone Number

Street Address

Zip Code

City

State

Requestor's Contact Information

Llene la siguiente sección SOLO si la persona que realiza esta solicitud no es el afiliado:

First Name

Last Name

Relationship to Enrollee

Phone Number

Street Address

Zip Code

City

State

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) and enter a brief explanation below.

Prescription Drug Information

¿Cuál es el nombre del medicamento y su concentración

Quantity Requested per Month

Dose

Verifique si compró el medicamento de apelación pendiente

If "Yes":

Date Purchased

Amount Paid & Attach Receipt

Pharmacy Name

Pharmacy Phone Number

Prescriber's Information

First Name

Last Name

Street Address

Zip Code

City

State

Phone Number

Fax Number

Important Notes: Expedited Decision 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.

CHECK THIS BOX IF YOU BELIEVE YOU 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. Enter 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.

Al presentar la apelación, se exige que incluya la firma de la persona que la solicita (el afiliado, el médico que receta al afiliado o el representante) y la fecha.

Signature

Date

Imprimir formulario

¿Necesita ayuda? Puede contar con nosotros.

Comuníquese con nosotros

Y0020_WCM_178064E_M Last Updated On: 11/10/2025

Solicitud de apelación para cobertura de medicamentos

Corrija los errores indicados a continuación:

Corrija los errores que se indican a continuación

Enrollee's Information

Enrollee's Contact Information

Requestor's Contact Information

Prescription Drug Information

Prescriber's Information

¿Necesita ayuda? Puede contar con nosotros.

Medicare Advantage

Prescription Drug Plans (PDP)

Inscripción

Elegibilidad

About Medicare

Planes de medicamentos recetados

Medicare

Recursos

Formularios de farmacia

Formularios de farmacia

Solicitudes de determinación de cobertura

Incorporación

Herramientas

Sales and Marketing

Enrollments

Solicitud de apelación para cobertura de medicamentos

Corrija los errores indicados a continuación:

Corrija los errores que se indican a continuación

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Information

Prescriber's Information

¿Necesita ayuda? Puede contar con nosotros.

Enrollee's Information

Requestor's Contact Information