Enrollee's Information

Enrollee's Name   Date of Birth  

Enrollee's Address  

City     State    Zip Code  


Enrollee's Plan ID Number 

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

Requestor's Information

Requestor's Name

Requestor's Relationship to Enrollee

Requestor's Address

City   State   Zip Code


Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:

Attach documentation showing the authority too represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted a t the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare


Name of prescription drug you are requesting

Name of Drug     Strength/quantity/dose

Have you purchased the drug pending appeal?
If Yes:
Date Purchased   Amount Paid $ attach copy of receipt

Name and telephone number of pharmacy  

Prescriber's Information



City   State  Zip Code

Office Phone   Fax

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 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. 

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.

Please explain your reasons for appealing

Attach additional pages, if necessary. Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

Signature of person requesting the coverage determination (the enrollee, or the enrollee’s prescriber or representative):

Signature           Signature Type       
Date:            6/13/2024