› Request for Redetermination of Medicare Prescription Drug Denial

Request for Redetermination of Medicare Prescription Drug Denial

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Because we Leon Health, Inc. denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

You may also ask us for an appeal through our website at www.leonhealth.com. Expedited appeal requests can be made by phone at 1-844-969-5366.

Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.

All fields with (*) are required.

Enrollee's Information

Enrollee's Name*

Date of Birth*

Enrollee's Address*

City*

State*

Zip Code*

Phone*

Enrollee's Member ID Number*

Is the requestor not the same as the enrollee?

Check this box if the person making this request is not the enrollee/prescriber

Requestor’s Name*

Relationship to Enrollee*

Address*

City*

State*

Zip Code*

Phone*

Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:

Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.

Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 15 MB.

Prescription drug you are requesting

Name of drug*

Strength/quantity/dose

Have you purchased the drug pending appeal?*

Yes

Date purchased*

Amount paid*

Please enter a number greater than or equal to 0.

Attach copy of receipt

Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 15 MB.

Name and telephone number of pharmacy*

Prescriber's Information

Name

Address

City

State

Zip Code

Office Phone

Fax

Office Contact Person

Important Note: Expedited Decisions

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

CHECK THE YES BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS (if you have a supporting statement from your prescriber, attach it to this request).

Yes

Please explain your reasons for appealing.

Attach additional pages, if necessary. Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage and have your prescriber address the Plan’s coverage criteria, if available, as stated in the Plan’s denial letter or in other Plan documents. Input from your prescriber will be needed to explain why you cannot meet the Plan’s coverage criteria and/or why the drugs required by the Plan are not medically appropriate for you.

Additional Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 15 MB, Max. files: 3.

Signature*

Enter the full name of the person requesting the appeal (the enrollee or the representative)