DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0976 NOTICE OF DENIAL OF MEDICARE PRESCRIPTION DRUG COVERAGE Date Enrollee's name Member number We have denied coverage or payment for the following prescription drug or drugs that you or your prescriber requested: We denied this request because: What if I don't agree with this decision? You have the right to appeal. If you want to appeal, you must request your appeal within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline. You have the right to ask us for a formulary exception if you believe you need a drug that is not on our list of covered drugs (formulary). You have the right to ask us for a coverage rule exception if you believe a rule such as prior authorization or a quantity limit should not apply to you. You can ask for a tiering exception if you believe you should get a drug at a lower cost-sharing amount. Your prescriber must provide a statement to support your exception request. Who may request an appeal? You, your prescriber, or your representative may request an expedited (fast) or standard appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to be your representative. Others may already be authorized under State law to be your representative. You can call us at: (______)______________ to learn how to appoint a representative. If you have a hearing or speech impairment, please call us at TTY: (______)______________. Form CMS-10146 (01/11) American LegalNet, Inc. www.FormsWorkFlow.com 1 IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS There are two kinds of appeals you can request: 1. Expedited (72 hours): You, your prescriber, or your representative can request an expedited (fast) appeal if you or your prescriber believe that your health could be seriously harmed by waiting up to 7 days for a decision. You cannot request an expedited appeal if you are asking us to pay you back for a prescription drug you already received. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your appeal. If your prescriber asks for an expedited appeal for you, or supports you in asking for one, and indicates that waiting for 7 days could seriously harm your health, we will automatically expedite your appeal. If you ask for an expedited appeal without support from your prescriber, we will decide if your health requires an expedited appeal. We will notify you if we do not give you an expedited appeal and we will decide your appeal within 7 days. 2. Standard (7 days): You, your prescriber, or your representative can request a standard appeal. We must give you a decision no later than 7 days after we get your appeal. What do I include with my appeal request? You should include your name, address, Member number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our formulary, your prescriber must indicate that all the drugs on any tier of our formulary would not be as effective to treat your condition as the requested off-formulary drug or would harm your health. How do I request an appeal? For an Expedited Appeal: You, your prescriber, or your representative should contact us by telephone or fax at the numbers below: Phone Fax For a Standard Appeal: You, your prescriber, or your representative should mail or deliver your written appeal request to the address below: What happens next? If you appeal, we will review your case and give you a decision. If any of the prescription drugs you requested are still denied, you can request an independent review of your case by a reviewer outside of your Medicare Drug Plan. If you disagree with that decision, you will have the right to further appeal. You will be notified of your appeal rights if this happens. Contact information: If you need information or help, call us at: Toll Free TTY Other resources to help you: Medicare Rights Center Toll Free: 1-888-HMO-9050 Elder Care Locator Toll Free: 1-800-677-1116 Form CMS-10146 (01/11) American LegalNet, Inc. www.FormsWorkFlow.com Medicare Toll Free: 1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048 2