2022 Part D Appeal Request

Request for Redetermination of Medicare Prescription Drug Denial

Because HealthTeam Advantage 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.

Expedited appeal requests can be made by phone:

HealthTeam Advantage Plan I and Plan II PPO members call Elixir at 1-844-846-8003
HealthTeam Advantage Diabetes & Heart Care HMO members call Elixir at 1-833-684-7256

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.

* Indicates required fields
Requested by:
- Member
- Prescriber
- Other
Please submit an Appointment of Representative (AOR)
Max. file size: 50 MB.
You may download a blank AOR form by clicking here.
Enrollee's Information
Enrollee's Name
Date of Birth
MM slash DD slash YYYY
Enrollee's Address
Street Address Address Line 2 City State ZIP Code
Phone
Enrollee’s Member ID Number
is the person making this request the enrollee?
- Yes
- No
Complete the following section ONLY if the person making this request is not the enrollee:
Requestor’s Name
Requestor’s Relationship to Enrollee
Address
Street Address Address Line 2 City State ZIP Code
Phone
Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:
Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.
Max. file size: 50 MB.
Prescription drug you are requesting:
Name of drug:
Strength/quantity/dose:
Have you purchased the drug pending appeal?
- Yes
- No
Date purchased
MM slash DD slash YYYY
Amount paid:
Attach copy of receipt
Max. file size: 50 MB.
Name and telephone number of pharmacy:
Prescriber's Information
Name
Address
Street Address Address Line 2 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
- Expedite this request
(if you have a supporting statement from your prescriber, attach it to this request.)
Supporting documentation
Max. file size: 50 MB.
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.
Upload additional information (optional)
Drop files here or

Max. file size: 50 MB.
Signature of person requesting the appeal (the enrollee, or the enrollee’s prescriber or representative):

Please type in your name.
Date
MM slash DD slash YYYY
- By checking this box, you understand that your acknowledgement of this coverage determination (or the acknowledgement of the person authorized to act on your behalf under the laws of the State where you reside) means that you understand the contents of this request. If acknowledged by an authorized individual, this acknowledgement certifies that: 1) you are the person authorized under State law to complete this coverage determination and 2) that documentation of this authority is available upon request by HealthTeam Advantage or by Medicare.
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2022 Part D Appeal Request

Request for Redetermination of Medicare Prescription Drug Denial

Enrollee's Information

Prescription drug you are requesting:

Prescriber's Information

Important Note: Expedited Decisions

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