Redetermination request form

Request for redetermination of Medicare prescription drug denial

Because Aetna Assure Premier Plus (HMO D-SNP) 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.

Member’s information

Please provide the following information. All fields marked with an asterisk (*) are required.

*Name

*Date of birth

*Address 1

Address 2

*City

*State

Zip Code Example: 12345

*Phone Number Example: 1234567890

*Member ID

*Are you filing this request on behalf of someone else?

Yes, I am an appointed representative

No, I am the member

Please provide documentation showing the authority to represent the member (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted previously. You can mail, fax or email the documentation directly to us. You can find all our contact information on our “Contact us” page.

Your information

Please provide your information in the following fields. All fields marked with an asterisk (*) are required.

*Name

*Relationship Your relationship to member

*Address 1

Address 2

*City

*State

Zip Code Example: 12345

*Phone Number Example: 1234567890

Drug requested information

Please provide your information in the following fields. All fields marked with an asterisk (*) are required.

*drug requested

If known, include strength, quantity and dose

*Have you purchased the drug pending appeal?

Yes

Prescriber’s information

Please provide details of the coverage redetermination below. All fields marked with an asterisk (*) are required.

Prescriber’s information

Name

Address 1

Address 2

City

State

Zip Code Example: 12345

Office Phone Example: 1234567890

fax Example: 1234567890

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 request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination 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, you can fax it to us at 1-844-814-2260 or mail it to us at Aetna Assure Premier Plus (HMO D-SNP), Attn: Part D Appeals, Pharmacy Department, PO Box 818001 Cleveland, OH 44181-8001

Reason for appeal

Please explain your reason for appealing. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

*Signature

*Date Today's date

*Signature Type

What's covered?

For members

Redetermination request form

Request for redetermination of Medicare prescription drug denial

Member’s information

Your information

Drug requested information

Prescriber’s information

Important note: Expedited decisions