Request for Redetermination of Medicare Prescription Drug Denial

Because we CareSource® MyCare Ohio (Medicare-Medicaid Plan) 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:

CareSource
c/o CVS Caremark
MC109
P.O. Box 52000
Phoenix, AZ, 85072-2000
Fax Number
1-855-633-7673
Information

You may also ask us for an appeal through our website at: https://www.caresource.com/mycare/

Expedited appeal requests can be made by phone at: 1-855-475-3163. If you have a hearing or speech impairment, please call us TTY 1-800-750-0750 or 711. We are open 8 a.m. - 8 p.m. Monday through Friday and from Oct. 1 - Feb. 14 we are open the same hours 7 days a week.

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

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Representation documentation for appeal requests made by someone other than enrollee or the enrolleeā€™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.


Prescription drug you are requesting
Prescriber's Information

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.

If you have a supporting statement from your prescriber, attach it to this request.

CareSourceĀ® MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.

H8452_OHMMC226
File and Use 4/22/2014