Request Form For Reconsideration Of Medicare Prescription Drug Denial
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3Johns Hopkins Advantage MD
PO BOX 3538
Scranton, PA 18505
Request for Reconsideration of Medicare Prescription Drug Denial
Because your Medicare drug plan has upheld its initial decision to deny coverage of, or payment for, a
prescription drug you requested, you have the right to ask for an independent review of the plan’s decision.
You may use this form to request an independent review of your drug plan’s decision. You have 60
days from the date of the plan’s Redetermination Notice to ask for an independent review. Please complete
this form and mail or fax it to:
Requests from PDP and MA-PD
Customer Service:
Fax Numbers:
Plans: MAXIMUS, Federal Services
Toll-free: (877) 456-5302
Toll-free: (866) 825-9507
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302
Note about Appointed Representatives: Your prescriber may file a reconsideration request on your behalf
without being an appointed representative. If you want another individual, such as a family member or
friend, to request an independent review for you, that individual must be your appointed representative.
Contact your Medicare drug plan 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 Medicare (HIC) Number (as shown on your Medicare card)
Complete the following section ONLY if the person making this request is not the enrollee or the
enrollee’s prescriber (make sure to attach documentation showing the person’s authority to
represent enrollee for purposes of this request):
Requestor’s Name
Requestor’s Relationship to Enrollee
Address
City
State
Zip Code
Phone (
)
H3890_RCReqForm_0715 Approved 072215
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Parent category: Medical