Request for Redetermination of Medicare Prescription Drug Denial

CareSource® MyCare Ohio (HMO D-SNP) denied your request for coverage of (or payment for) Drug Name. You have the right to ask us for a redetermination (appeal) of our decision. Use this form to appeal this decision.

Fax or mail your completed form and any supporting information to:

Address:

Express Scripts
ATTN: Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588

Fax Number
1-877-852-4070

You may ask for an appeal within 65 days of the date of our Notice of Denial of Medicare Prescription Drug Coverage.

You can also file an appeal through our website at express-scripts.com.

Expedited appeal requests can be made by phone at 1-800-935-6103 (TTY: 1-800-716-3231).

Your prescriber can ask for an appeal on your behalf. If you want another person (like a family member or friend) to file an appeal for you, that person must be your representative. Call us at 1-855-475-3163 (TTY: 1-833-711-4711 or 711) to learn how to name a representative.

Plan Enrollee Information

Enrollee Name:

Date of Birth:

Mailing Address:

City:

State:

ZIP Code:

Phone:

Member ID Number:

Representative Information

Complete this section ONLY if the person making this request is not the enrollee or the enrollee’s prescriber.

Representative Name:

Relationship to Enrollee:

Street Address:

City:

State:

ZIP Code:

Phone:

You must attach documentation showing your authority to represent the enrollee (like a completed Form CMS-1696 or a written equivalent) if it wasn’t submitted at the coverage determination level. For more information on appointing a representative, call us 1-855-475-3163 (TTY: 1-833-711-4711 or 711)

Prescription & Prescriber Information

Name of drug you asked for:

Strength/quantity/dose:

Did you already purchase this drug?

Yes No

Date Purchased:

Amount Paid:

(Attach copy of receipt)

Pharmacy Name:

Pharmacy Phone Number:

Prescriber Name:

Office Address:

City:

State:

ZIP Code:

Office Phone:

Office Fax:

Office Contact Person:

Do you need an Expedited (Fast) Decision?

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS

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

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’ll automatically give you a decision within 72 hours. You can’t ask for an expedited appeal if you’re asking us to pay you back for a drug you already have.
If you don’t get your prescriber's support for an expedited appeal, we’ll decide if your case requires a fast decision.

Explain why you think this Drug should be covered

Attach any additional information you think may help your case, like statement from your prescriber or medical records.
Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage.
Your prescriber will need to explain why you can’t meet our plan’s coverage rules and/or why the drugs required by the plan aren’t medically appropriate for you.

Other Information we should consider:

Sign & Submit this Form

Signature of person requesting the appeal (the enrollee, prescriber or representative)

Signature:

Date:

H6396_OH-SNP-M-4148843_C