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 and have your
prescriber address the Plan’s coverage criteria, if available, as stated in the Plan’s denial
letter or in other Plan documents. Input from your prescriber will be needed to explain why
you cannot meet the Plan’s coverage criteria and/or why the drugs required by the Plan are
not medically appropriate for you.
Signature of person requesting the appeal (the enrollee or the representative):
click to sign
click to edit