Request for Redetermination of Medicare Prescription Drug Denial
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1 Request for Redetermination of Medicare Prescription Drug Denial Because we BlueCross BlueShield of North Carolina (BCBSNC) 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: BCBSNC Part D Appeals Fax Number : P.O. Box Winston-Salem, NC You may also ask us for an appeal through our website at Expedited appeal requests can be made by phone at For Blue Medicare HMO, For Blue Medicare PPO, or for Blue Rx members. 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 Enrollee s Address Date of Birth 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: 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. Y0079_5631 File and Use
2 Prescription drug you are requesting: Name of drug: Strength/quantity/dose: Have you purchased the drug pending appeal? If Yes : Yes No 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. Signature of person requesting the appeal (the enrollee, or the enrollee s prescriber or representative): Date: Y0079_5631 File and Use
3 (PDP) Multi-language Interpreter Services English: ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call the Customer Services number on the back of your member ID card. Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a Servicio de Atención al Cliente al número que figura al dorso de su tarjeta de identificación. Chinese: 注意 : 如果您講廣東話或普通話, 您可以免費獲得語言援助服務 請撥打您會員 ID 卡背面的客服部電話號碼 Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số Dịch vụ khách hàng trên mặt sau thẻ thành viên ID của bạn. Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 가입자 ID 카드뒷면에있는고객서비스전화번호로전화해주십시오. French : ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Téléphonez le Service clients au numéro qui figure au dos de votre carte de membre. ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم خدمة العمالء Arabic: الموضح على ظهر بطاقة هوية العضو الخاصة بك. Hmong : LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau tus nab npawb xovtooj ntawm Lub Chaw Pab Cuam Tswv Cuab uas nyob sab tom qab koj daim npav tswv cuab ID. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Позвоните в Отдел обслуживания по номеру, указанному на оборотной стороне вашей карточки участника. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tawagan ang numero ng Serbisyo sa Kostumer sa likod ng Id kard ng miyembro. Gujarati: Khmer: German: Hindi: Y0079_7585 PA U12555h સ ચન : જ તમ ગ જર ત બ લત હ વ ત તમ ર મ ટ ભ ષ સ વ ઓ નન:શ લ ક ઉપલબ ધ છ..તમ ર સભ યપદ ઓળખપત રન (આઈ.ડ ) પ છળન બ જ પર આપ લ ગ ર હક સ વ ઓન ન બર પર ક લ કર. ច ណ ប រស នបរ ប កអ នកន យ យជ ភ ស ខ ម រ បសវ កម ជ ន យខ នកភ ស ម ននតល ជ នសប ម រ ប កអ នកប យម នគ តថ ល ស ម ប ប ក ន បសវ អ ត ល ជនប យបប រ បលមទ រស ព ទប ខ ងមនងក តសម ជ កររស ប កអ នក ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufen Sie die Nummer des Kundenservice an, die auf der Rückseite Ihrer Mitglieds-ID-Karte angegeben ist. ध य न द : यदद आप द न द ब लत त आपक दलए म फ त म भ ष स यत स व ए उपलब ध अपन सदस य आईड क ड क प छ म ज द ग र क स व ए न बर पर क ल कर
4 (PDP) Multi-language Interpreter Services Lao: Japanese: ເຊ ນຊາບ: ຖ າທ ານເວ າພາສາລາວ, ມການບ ລການຊ ວຍເຫອດ ານພາສາຟຣໃຫ ທ ານ. ໃຫ ໂທຫາ ຂອງຝ າຍບ ລການລ ກຄ າຕາມເບ ຢ ດ ານຫ ງບ ດຂອງທ ານ. 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 メンバー ID カードの裏面のカスタマーサービス番号にお電話ください Blue Cross and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
5 Discrimination is Against the Law (PDP) Non-Discrimination and Accessibility Notice Blue Cross and Blue Shield of North Carolina ( BCBSNC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. BCBSNC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. BCBSNC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified interpreters Written information in other formats (large print, accessible electronic formats, etc.) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Customer Service by calling the number on the back of your ID card. If you believe that BCBSNC has 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 with: BCBSNC, PO Box 2291, Durham, NC 27702, Attention: Civil Rights Coordinator-Privacy, Ethics & Corporate Policy Office, Telephone , Fax , TTY civilrightscoordinator@bcbsnc.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Civil Rights Coordinator-Privacy, Ethics & Corporate Policy Office 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 This Notice and/or attachments may have important information about your application or coverage through BCBSNC. Look for key dates. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Customer Service at the number on the back of your ID card. Blue Cross and Blue Shield of North Carolina is an HMO, PPO, and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. Y0079_7600 PA U12576h, 8/16
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