Request Type


Please select the type of request you are submitting


 


Terms and DefinitionsNondiscrimination Notice
Request Type Selection
  • Coverage Determination
  • -
  • Is the first time you are asking for a decision about your Part D drugs.

  • Coverage Redetermination
  • -
  • Is an appeal to your Part D health plan about a part D drug coverage decision that has already been made.


Timeline
  • Coverage Determination
  • -
  • Please allow 72-hour turnaround for standard requests.

  • Coverage Redetermination
  • -
  • Please allow 7 calendar days for standard requests.


Member's Representative
  • Representative
  • -
  • An individual either appointed by the member or authorized under State or other applicable law to act on behalf of the member in requesting a coverage determination or in dealing with any of the levels of appeals.


A notice is an "equivalent written notice" if it:

  • Includes the name, address, and telephone number of enrollee;
  • Includes the enrollee's HICN;
  • Includes the name, address, and telephone number of the individual being appointed;
  • Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually indentifying information to the representative;
  • Is signed and date by the enrollee making the appointment; and
  • Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment.