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REQUEST FOR PART D REDETERMINATION

Because KelseyCare Advantage 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 your Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
 
Expedited appeal requests can be made by phone at 1-866-535-8343.
 
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.
 
​Please complete and submit the following secure online form

 Redetermination Form

Enrollee Information









Prescription Drug you are requesting





Prescriber Information









Important Note: Expedited Decisions

If you or your prescriber believe that waiting 72 hours 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 72 hours could serious hare your health, we will automatically give you a decision within 24 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.

Please explain your reasons for appealing.

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.

Submit