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.
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.
Medicare Prescription Drug Coverage Provider Communication Form
This form was developed by the AMA and other entities to provide pharmacists with a form to be faxed to an enrollee's prescriber when a requested medication is not covered by a plan sponsor. The form will allow the prescriber to consider whether to change the enrollee's prescription, seek prior authorization, or initiate the exceptions process. The form can also be used to seek prescription information from prescribers immediately while the enrollee is waiting at the drugstore.
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.
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”:
- Model Coverage Determination Req Form and Instructions [ZIP, 84KB]
- Model Redetermination Request Form and Instructions [ZIP, 65KB]
- Medicare Prescription Drug Coverage Provider Communication Form Rev Dec2012 [ZIP, 89KB]
- Request for Reconsideration of Medicare Prescription Drug Denial [ZIP, 88KB]
- Chapter 18 of the Prescription Drug Benefit Manual [ZIP, 1MB]
- Page last Modified: 02/06/2017 12:32 PM
- Help with File Formats and Plug-Ins