You have the right to an appeal if you disagree with a coverage determination decision. The first stage of an appeal is known as a redetermination. Whether you disagree completely or partly with our original decision, your right to a redetermination applies. People who were not involved in the original decision will carefully consider your case.

What kinds of decisions can be

You can appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a drug, if you think your reimbursement should have been larger, or if you think a cost-sharing amount is too high. Finally, you may also appeal if we deny your exception request.

Standard and Expedited Redetermination Requests

Standard Redetermination Request

An appeal concerning reimbursement for a benefit you’ve already received is a standard redetermination request. If your appeal concerns a benefit you have not received, you and your doctor will first need to decide whether you need an expedited (fast) redetermination. We will notify you of our decision on a standard redetermination within seven days of your request.

To request a standard redetermination, submit the form here.

You may also mail your completed form to: Blue MedicareRx (PDP)
Coverage Determination/Appeals Department
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000
Fax to: 1-855-633-7673

Expedited (Fast) Redetermination Request

You can request a fast redetermination if you or your doctor believes your health would be seriously harmed by waiting up to 7 days for a decision. If we grant your request, we will give you a decision within 72 hours of receiving the request.

We automatically provide a fast redetermination if your doctor requests it for you or supports your request with a written statement. You or your doctor may check on the status of your appeal at 1-800-294-5979.

To request a fast redetermination, call 1-855-344-0930, 24 hours a day, 7 days a week. For TTY/TDD, call 711. Or fax your documents to 1-855-633-7673.

Providing information to support your appeal

If we need additional information to make a decision on your appeal, we may contact you. You also have the right to include additional information with your appeal form. For example, you may wish to include a doctor’s statement or other health records to support your request.

Getting information about your appeal

You have the right to ask us for a copy of information related to your appeal. Contact Us by phone or write to the address listed above.

Who may file an appeal?

For a standard appeal, you or your appointed representative may file the request. For an expedited (fast) appeal, you, your appointed representative, or your prescribing doctor may file.

Appointing a representative

To appoint a relative, friend, advocate, doctor, or anyone else to act as your legal representative, you and that person will need to complete and sign an Appointment of Representative form (PDF). You must complete this form and file it with each request for a redetermination.

How soon must an appeal be filed?

You need to file your appeal within 60 calendar days from the date on the notice of a denial of coverage. However, we can give you more time if you have a good reason for missing the deadline.

How does the appeals process work?

There are five possible levels to the appeals process. At each level, your request for coverage benefits or payment is considered and a decision is made. The decision may be partly or completely in your favor or it may be completely denied (turned down).

If your appeal is denied, either completely or partly, you have the right to take your appeal to the next level. To ensure a fair decision, all appeals after the first level are decided by Medicare or the federal court system.

For more information on appeals, see Chapter 7, Section 4, of our Evidence of Coverage document.

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