Fillable Request for Redetermination of Medicare Prescription Drug Denial (John Hopkins Medicine Medicare Plan)

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Request for Redetermination of Medicare Prescription Drug Denial (John Hopkins Medicine Medicare Plan)

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The Request for Redetermination of Medicare Prescription Drug Denial (John Hopkins Medicine Medicare Plan) form is 3 pages long and contains:

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  • 3 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

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Y0124_RDReqFormHMO0920_C
Request for Redetermination of Medicare Prescription Drug Denial
Because we, Johns Hopkins Advantage MD (HMO), 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:
Address:
Johns Hopkins Advantage MD
c/o CVS Caremark Part D Services
Coverage Determination and Appeals Department
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000
Fax Number:
1-855-633-7673
You may also ask us for an appeal through our website at www.hopkinsmedicare.com.
Expedited appeal requests can be made by phone at 1-877-293-4998 (option 2), TTY: 711,
October 1 through March 31 – Monday through Sunday, 8 a.m. to 8 p.m. and April 1 through
September 30 – Monday through Friday, 8 a.m. to 8 p.m.
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.
Y0124_RDReqFormHMO0920_C
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 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:
☐
Y0124_RDReqFormHMO0920_C
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:
___________________
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Request for Redetermination of Medicare Prescription Drug Denial (John Hopkins Medicine Medicare Plan)

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Completed 25 May 2021

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