Request For Redetermination Of Medicare Prescription Drug Denial

Request For Redetermination Of Medicare Prescription Drug Denial - Idaho Blue Cross

Request for Redetermination of Medicare Prescription Drug Denial

Because we, Blue Cross of Idaho, 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: CVS Caremark

Fax Number: 1-855-633-7673

Attn: Prior Authorization – Part D

620 Epsilon Drive

Pittsburgh, PA 15238

You may also ask us for an appeal through our website at

Expedited appeal requests can be made by phone at 1-855-344-0930, TTY 1-866-236-1069.

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 Plan 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.

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Request For Redetermination Of Medicare Prescription Drug Denial - Idaho Blue Cross