Request for Redetermination of Medicare Prescription Drug Denial
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- Sophie Mills
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1 Request for Redetermination of Medicare Prescription Drug Denial Because we BlueRx (PDP) 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. This form may be sent to us by mail or fax: Address: Fax Number: BlueRx (PDP) Attn: Clinical Review Department 1305 Corporate Center Drive Eagan, MN You may also ask us for an appeal through our website at Expedited appeal requests can be made by phone at (AL) / (TN), 711 TTY, 8 a.m. to 8 p.m., seven (7) days a week. From February 15 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day. 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. Enrollee s Information Enrollee s Name Date of Birth Enrollee s Address Phone Enrollee s Plan 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 Address Phone Representation documentation for appeal requests made by someone other than enrollee or the enrollee s prescriber:
2 Attach 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 or Medicare. 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: $ (attach copy of receipt) Name and telephone number of pharmacy: Prescriber's Information Name Address 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. 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. 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.
3 Signature of person requesting the appeal (the enrollee, or the enrollee s prescriber or representative): Date: BlueRx (PDP) is a Medicare-approved Part D plan. Enrollment in BlueRx (PDP) depends on CMS contract renewal. BlueRx (PDP) is provided by Blue Cross and Blue Shield of Alabama and UTIC Insurance Company, independent licensees of the Blue Cross and Blue Shield Association.
4 Notice of Nondiscrimination Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association, complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Alabama: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages If you need these services, contact our 1557 Compliance Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person or by mail, fax, or at: Blue Cross and Blue Shield of Alabama, Compliance Office, 450 Riverchase Parkway East, Birmingham, Alabama 35244, Attn: 1557 Compliance Coordinator, , 711 (TTY), (fax), 1557Grievance@bcbsal.org ( ). If you need help filing a grievance, our 1557 Compliance Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C , , (TDD). Complaint forms are available at Foreign Language Assistance Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711) Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). انتباه: ا ذا كنت تتحدث العربية توجد خدمات مساعدة فيما يتعلق باللغة بدون تكلفة متاحة لك. اتصل ب Arabic: (الهاتف النصي: 711) C
5 German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). French: ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Gujarati: ધ ય ન આપ : જ તમ ગ જરય ત બ લતય હ, ત ભય ષય સહય તય સવય, તમય રય મય ટ નન શલ ક ઉપલબ ધ છ પર ક લ કર (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Hindi: ध य न द : अगर आपक भय षय ह द, त आपक ल ए भय षय स य तय स वय ए नन श लक उप ब ध (TTY: 711) पर क कर Laotian: ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Turkish: DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz (TTY: 711) irtibat numaralarını arayın. Italian: ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください MKT
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