Medicare Prescription Drug Redetermination Request



Enrollee Information

First Name
Middle Initial
Last Name
Date of Birth
Enrollee’s Member ID #
Street One
Street Two
City
Zip
Phone

Prescriber Information

First Name
Middle Initial
Last Name
Street One
Street Two
City
Zip
Office Contact Person
Office Phone
Fax

Expedited Decisions

Additional Information

Prescription drug you asked your plan to cover
Additional information we should consider
Signature
Redetermination (Denial) Notice
PDF Format*
Supporting Document
PDF Format