• Request for Medicare Part D Redetermination After Denial of Medication Request

Request for Medicare Part D Redetermination After Denial of Medication Request

Please use this form to initiate a Medicare Part D redetermination. Once we receive this form we will contact you at the number you provide to confirm and process your request.

If the person filing this appeal (redetermination) is not the prescriber or not an authorized representative of the member, a "Personal Representative Authorization - Filing an Appeal" form will be sent to the member to authorize the representative to file on his or her behalf.

* Indicates a required field

Member information

Date of birth


Requestor Information

If the person requesting this appeal is not the member, please complete the section below.


Medication Information

*Name of drug requested (include strength and quantity, if known)


Denial Information

Date of denial

Reason for appealing

Additional Information