Request for Redetermination of Medicare Prescription Drug Denial
Because we (CareSource Advantage Zero Premium™ (HMO) and CareSource Advantage® (HMO)) 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:
ATTN: Benefit Coverage Review Department
PO Box 66587
St. Louis, MO 63166-6587
You may also ask us for an appeal through our website at: https://www.caresource.com/oh/members/tools-resources/grievance-appeal/part-d-prescription-plan-rights/medicare/
Expedited appeal requests can be made by phone at: 1-800-488-0134. If you have a hearing or speech impairment, please call us TTY 1-800-750-0750 OR 7-1-1. We are open 8 a.m. - 8 p.m. Monday through Friday and from Oct. 1 - Mar. 31, we are open the same hours seven 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.