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Request for Redetermination of Medicare Prescription Drug Denial

Please submit this form to make a request for redetermination of Medicare prescription drug denial.

Because we Independence Blue Cross 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.

Expedited appeal requests can be made by phone at:
Keystone 65 HMO : 1-800-645-3965 (speech- and hearing-impaired 711)
Personal ChoiceSM PPO: 1-888-718-3333 (speech — and hearing impaired 711).

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. Please call us to learn how to name a representative.

Member's information (* Required Fields)


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Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor's information












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Yes
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If "Yes":










Prescriber's information


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REQUEST FOR EXPEDITED REVIEW: 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.

I need a decision within 72 hours.

Reason for appealing

Provide 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.








To ensure your privacy, all information will be sent via a secure connection. Independence Blue Cross will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.

Website Last Updated: 10/1/2016
Y0041_HM_17_43499 Approved 10/7/2016