Plan Name: Contract ID:
Formulary ID: Plan ID:

Request for Reconsideration of Medicare Prescription Drug Denial

Because your Medicare drug plan has upheld its initial decision to deny coverage of, or payment for, a prescription drug you requested, you have the right to ask for an independent review of the plan’s decision. You may use this form to request an independent review of your drug plan’s decision. You have 60 days from the date of the plan’s Redetermination Notice to ask for an independent review. Please complete this form and mail or fax it to:

Requests from PDP and MA-PD Plans:
MAXIMUS, Federal Services
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302
Customer Service:
Toll-free: (877) 456-5302
Fax Numbers:
Toll-free: (866) 825-9507
(585) 425-5301

Note about Representatives: Your prescriber may file a reconsideration request on your behalf without being an appointed representative. If you want another individual, such as a family member or friend, to request an independent review for you, that individual must be your representative. Contact your Medicare drug plan to learn how to name a representative.


Enrollee's Information


Prescription drug you asked your plan to cover



Prescribing Physician’s Information


Expedited Decisions If you or your prescribing physician or other prescriber believe that waiting for a standard decision (which will be provided within 7 days) could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician or other prescriber indicates that waiting 7 days could seriously harm your life or health or ability to regain maximum function, the independent review organization will automatically give you a decision within 72 hours. This timeframe may be extended for up to 14 calendar days if your case involves an exception request and we have not received the supporting statement from your doctor or other prescriber supporting the request, OR the person acting for you files an appeal request but does not submit proper documentation of representation. If you do not obtain your physician’s or other prescriber’s support for an expedited appeal, the independent review organization will decide if your health condition requires a fast decision.




Please attach any additional information you have related to your appeal such as a statement from your prescribing physician or other prescriber and relevant medical records.

PDF files only.

Additional information we should consider:


Important: Please include a copy of the Redetermination (denial) Notice you received from your drug plan with this request.


PDF files only.


Signature of person requesting the appeal (the enrollee or the representative):