Online Request for Medicare Part D Redetermination

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 form will be sent to the member to authorize the representative to file on his or her behalf.

Part D Redetermination Form

Include strength and quantity, if known