Fillable Request for Redetermination of Medicare Prescription Drug Denial (Anthem Inc)

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Request for Redetermination of Medicare Prescription Drug Denial (Anthem Inc)

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H6229_20_112033_U CMS Accepted 08/24/2019
5246-MTMRX603EUNVA1CA 061319
Request for Redetermination of Medicare Prescription Drug Denial
Because we, Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan), 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. This form may be sent to us by
mail or fax:
Fax Number:
1-888-458-1407
Address:
Complaints, Appeals & Grievances
Mailstop: OH0205-A537, 4361 Irwin Simpson Rd
Mason, OH, 45040
You may also ask us for an appeal through our website at duals.anthem.com.
Expedited appeal requests can be made by phone at 1-833-370-7466, TTY users can call 711,
24 hours a day, 7 days a week.
Who May Make a Request: 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. Contact us to learn how to name a representative.
Enrollee’s Information
Enrollee’s Name
_____________________________________
Date of Birth
______________________
Enrollee’s Address
______________________________________________________________________
City
___________________________________________
State
___________
Zip Code
______________
Phone ___________________________________________
Enrollee’s Member ID Number ___________________________________________
Complete the following section ONLY if the person making this request is not the
enrollee:
Requestor’s Name ______________________________________________________________________
Requestor’s Relationship to Enrollee ______________________________________________________
Address
_______________________________________________________________________________
City
___________________________________________
State
___________
Zip Code
______________
Phone ___________________________________________
Representation documentation for appeal requests made by someone other than enrollee
or
the enrollee’s prescriber:
Attach documentation showing the authority to represent the enrollee (a completed
Authorization of Representation Form CMS-1696 or a written equivalent) if it was not
submitted at the coverage determination level. For more information on appointing a
representative, contact your plan or 1-800-Medicare, 24 hours a day, 7 days a week. TTY
H6229_20_112033_U CMS Accepted 08/24/2019
5246-MTMRX603EUNVA1CA 061319
users call: 1-877-486-2048
Prescription drug you are requesting:
Name of Drug:
____________________________
Strength/quantity/dose:
_________________________
Have you purchased the drug pending appeal?
☐ Yes ☐ No
If “Yes”: Date purchased: Amount paid:
$ (attach copy of receipt)
Name and telephone number of pharmacy:
Prescriber’s Information
Name ________________________________________________________________________________
Address
______________________________________________________________________________
City
___________________________________________
State
___________
Zip Code
______________
Office Phone _______________________________________
Fax ____________________________
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):
______________________________________________________ Date: ___________________
H6229_20_112033_U CMS Accepted 08/24/2019
5246-MTMRX603EUNVA1CA 061319
Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts
with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Anthem Blue Cross
is the trade name for Blue Cross of California. Anthem Blue Cross and Blue Cross of California
Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered
trademark of Anthem Insurance Companies, Inc.
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Request for Redetermination of Medicare Prescription Drug Denial (Anthem Inc)

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Completed 18 May 2022

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