Request for Redetermination of Medicare Prescription Drug Denial
Because we CareSource Advantage Zero Premium™ (HMO), CareSource Advantage® (HMO) and CareSource Advantage Plus™ (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:
c/o Medicare Clinical Appeals
PO Box 66588
St. Louis, MO 63166-6588
You may also ask us for an appeal through our website at: https://www.caresource.com/members/ohio/medicare/my-right-to-file-a-grievance-or-appeal/part-d-prescription-drug-plan-rights/
Expedited appeal requests can be made by phone at: 1-844-607-2827. 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.