Forms

Overview

This section provides specific information of particular importance to beneficiaries receiving Part D drug benefits through a Part D plan.  Included in the "Downloads" section below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes (with the exception of the Appointment of Representative form, which has a link in the "Related Links" section below).

Appointment of Representative Form CMS-1696

If an enrollee would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on his or her behalf, the enrollee and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. (See the link in "Related Links" section). The enrollee's prescribing physician or other prescriber may request a coverage determination, redetermination or IRE reconsideration on the enrollee's behalf without having to be an appointed representative.

Request for a Medicare Prescription Drug Coverage Determination

An enrollee, an enrollee's representative, or an enrollee's prescriber may use this model form to request a coverage determination, including an exception, from a plan sponsor.

February 2019: The Request for a Medicare Prescription Drug Coverage Determination model notice has been updated to expand the Please Explain Your Reasons for Appealing section. There are no changes to the instructions for this notice.

Request for a Medicare Prescription Drug Redetermination

An enrollee, an enrollee's representative, or an enrollee's prescriber may use this model form to request a redetermination (appeal) from a plan sponsor.

February 2019: The Request for a Medicare Prescription Drug Redetermination model notice has been updated to include revised Maximus contact information, and additional guidance for attaching additional information. There are no changes to the instructions for this notice.

Request for Reconsideration of Medicare Prescription Drug Denial

An enrollee or an enrollee's representative may use this model form to request a reconsideration with the Independent Review Entity. You may download this form by clicking on the link in the "Downloads" section below.

February 2019: The Request for Reconsideration of Medicare Prescription Drug Denial model notice has been updated to include additional drug history and an expanded rationale field. 

Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal

An enrollee or an enrollee's representative may use the form “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100” to request an ALJ hearing, or to request a review of an Independent Review Entity's dismissal.   

The direct link to the form “OMHA-100”:

https://www.hhs.gov/sites/default/files/OMHA-100.pdf                                    

Page Last Modified:
11/09/2019 02:45 AM