Request for Redetermination of Medicare Prescription Drug Denial

Please submit this form to make a request for redetermination of Medicare prescription drug denial.

Because we, Independence Blue Cross, 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.

Expedited appeal requests can be made by phone at:

Keystone 65 HMO : 1-800-645-3965 (speech- and hearing-impaired 711)
Personal Choice^SM PPO: 1-888-718-3333 (speech- and hearing-impaired 711)

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. Please call us to learn how to name a representative.

Member’s Information (* required fields)

* First Name:

* Last Name:

* Date of birth:

* Address:

Address 2:

* City:

* State:

* ZIP:

* Phone Number:

* Member ID (numeric portion only):

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

Requestor’s Information

First name:

Last name:

Requestor’s relationship to member:

Address:

Address 2:

City:

State:

ZIP:

Phone number:

Drug Information (* required fields)

* Name of prescription drug you are requesting (if known, include strength and quantity requested per month):

* Have you purchased the drug pending appeal?

Yes

If you answered “Yes” to the above:

Date purchased:

Amount paid:

Pharmacy name:

Pharmacy phone number:

Prescriber’s information (* required fields)

* First name:

* Last name:

Address:

Address 2:

City:

State:

ZIP:

* Phone number:

Fax number:

REQUEST FOR EXPEDITED REVIEW: 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 need a decision within 72 hours.

Reason for appealing

Provide 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.

Explanation: