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 and exceptions, and appeals processes.

Appointment of Representative Form CMS-1696

If a beneficiary would like to appoint a person to file a grievance, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request.

Request for a Medicare Prescription Drug Coverage Determination

A beneficiary, a beneficiary's appointed representative, or a beneficiary's prescribing physician may use this model form to request a coverage determination from a plan sponsor.

Coverage Determination Request Form for Physicians

This form was developed by AHIP, the AMA, and other entities to provide physicians with a form to be used to request a coverage determination or exception, support a tiering or formulary exception request, or request prior authorization.  It may be completed by an enrollee's prescribing physician and mailed or faxed to the enrollee's 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 a beneficiary's physician when a requested medication is not covered by a plan sponsor.  The form will allow the physician to consider whether to change the patient's prescription, seek prior authorization, or initiate the exceptions process.  The form can also be used to seek prescription information from physicians immediately while the patient is waiting at the drugstore.

Request for Reconsideration of Medicare Prescription Drug Denial

A beneficiary or a beneficiary's appointed representative may use this model form to request a reconsideration with the Independent Review Entity.  The request form is contained in Appendix 13 to Chapter 18 of the Prescription Drug Benefit Manual.  You may view Appendix 13 by clicking on the link in the "Downloads" section below.

Part D Late Enrollment Penalty Reconsideration Notice

The Part D Late Enrollment Penalty reconsideration notice provides a detailed explanation of an enrollee's right to request a reconsideration of his or her Late Enrollment Penalty. A Part D plan sponsor must complete the notice and send it to an enrollee when the plan first sends the enrollee a letter notifying him or her about the imposition of a Late Enrollment Penalty. The notice is contained in Appendix 14 to Chapter 18 of the Prescription Drug Benefit Manual. You may also download a Microsoft Word version of Appendix 14 by clicking on the link in the "Downloads" section below.

Part D Late Enrollment Penalty Reconsideration Request Form

An enrollee may use this form to request an appeal of a Late Enrollment Penalty decision. The enrollee must complete the form, sign it, and send it to the Independent Review Entity as instructed in the form. The form is contained in Appendix 15 to Chapter 18 of the Prescription Drug Benefit Manual. You may also download a Microsoft Word version of Appendix 15 by clicking on the link in the "Downloads" section below

Downloads
Appointment of Representative Form CMS-1696 [pdf, 120kb] Model Coverage Determination Request Form [pdf, 23kb] Instructions Model Coverage Determination Request [pdf, 15kb] Model Coverage Determination Request Form for Physicians [pdf, 85kb] Medicare Prescription Drug Coverage Provider Communication Form [pdf, 23kb] Appendix 13 - Request for Reconsideration [zip, 7kb] Appendix 14 - Part D Late Enrollment Penalty Reconsideration Notice [zip, 5kb] Appendix 15 - Part D Late Enrollment Penalty Reconsideration Request Form [zip, 9kb] Model Notices [zip, 58kb] Chapter 18 of the Prescription Drug Benefit Manual [pdf, 348kb]
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Page Last Modified: 05/27/2008 10:08:13 AM
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