Request For Redetermination Of Medicare Prescription Drug Denial

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.

Signature of person requesting the appeal (the enrollee, or the enrollee’s prescriber or representative):

Date:

Blue Cross of Idaho is a health plan with a Medicare contract. Enrollment in Blue Cross of Idaho plans depends on contract

renewal.

All beneficiaries must use their plan sponsor’s network pharmacies to access their prescription drug benefit, except

under non-routine circumstances. Quantity limitations and restrictions may apply.

An Independent Licensee of the Blue Cross and Blue Shield Association.

Request For Redetermination Of Medicare Prescription Drug Denial - Idaho Blue Cross Page 2