Request for Medicare Part D Drug Redetermination after Denial

 

Please use this form to ask us to reconsider the Part D drug you were denied. Once we receive this form, we will contact you to confirm and process your request.

Request for Medicare Part D Drug Redetermination after Denial 

Include area code.

MM/DD/YYYY

If you are not the prescriber or not an authorized representative of the member, a form will be sent to the member to authorize you to file on their behalf.

Include strength and quantity, if known.

MM/DD/YYYY

Please use this space for any additional comments you may have.