CurrentCareSourcePolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Procedure and form for CareSource Dual Advantage (HMO D-SNP) enrollees (or their prescribers/representatives) to request a redetermination (appeal) of a denied Medicare prescription drug coverage decision.

Policy Summary

PayerCareSource

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionEnrollee, prescriber, or authorized representative may file a redetermination request and submit supporting documentation by fax or mail to Express Scripts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daystimeframe to file an appeal from date of Notice of Denial

72 hoursdecision timeframe for expedited (fast) appeals

7 daysstandard decision wait that may be harmful to health if expedited requested

1-833-230-2020representative & inquiries phone

Fax 1-877-852-4070submission fax

Supporting documentation & submission requirements

Supporting documentation and submission requirements

Information and documentation required to support a redetermination request:

Attach a copy of the Notice of Denial of Medicare Prescription Drug Coverage.

Attach any additional information that may help the case, such as a statement from the prescriber or relevant medical records.

Prescriber explanation: the prescriber must explain why the enrollee cannot meet the plan's coverage rules and/or why the drugs required by the plan are medically inappropriate for the enrollee.

Prescription and prescriber information: include drug name, strength/quantity/dose, prescriber name, office address, phone and fax, and office contact person.

If the drug was already purchased: provide date purchased, amount paid, pharmacy name and phone, and attach a copy of the receipt. Note: expedited appeals cannot be requested solely for reimbursement of an already obtained drug.

Policy Summary

PayerCareSource

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeAdministrative update (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionEnrollee, prescriber, or authorized representative may file a redetermination request and submit supporting documentation by fax or mail to Express Scripts.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Redetermination (Appeal) Request Process

Prior Authorization

Redetermination (Appeal) Request Process

Enrollees, their prescribers, or an authorized representative may request a redetermination (appeal) of a denied Medicare prescription drug coverage decision. File within 65 days of the date on the Notice of Denial. You may submit the completed appeal form and supporting documentation by mail or fax to Express Scripts; expedited requests may be made by phone when prescriber attests harm from waiting.

Who may file: the enrollee, the enrollee's prescriber, or an authorized representative (to name a representative call 1-833-230-2020; TTY: 1-833-711-4711 or 711).
Filing deadline: within 65 days of the date of our Notice of Denial of Medicare Prescription Drug Coverage.
Submission methods: mail to Express Scripts Attn: Medicare Appeals, P.O. Box 66588, St. Louis, MO 63166-6588 or fax completed form and supporting information to 1-877-852-4070.
Expedited (fast) appeals: check the expedited box and attach a prescriber statement if you believe waiting up to 7 days for a standard decision could seriously harm life, health, or ability to regain maximum function; prescriber-supported requests will be decided within 72 hours. Expedited requests can also be made by phone at 1-800-935-6103 (TTY: 1-800-716-3231).
You cannot request an expedited appeal solely to be reimbursed for a drug already obtained.

Key definitions used in this policy

Expedited appeal — definition and timeframes

DefinitionExpedited (fast) appeal — an appeal decision requested to be completed within 72 hours when waiting up to 7 days for a standard decision could seriously harm the enrollee's life, health, or ability to regain maximum function.

Decision timeframe (expedited)72 hours from receipt when expedited is granted or automatically triggered by prescriber attestation.

Standard decision comparisonStandard redetermination decisions may take up to 7 days; expedited is only for cases where waiting could seriously harm the enrollee.

How expedited is requestedCheck the expedited box on the form and attach a supporting statement from the prescriber, or request by phone at 1-800-935-6103 (TTY: 1-800-716-3231).

Automatic expedited handlingIf the prescriber indicates that waiting 7 days could seriously harm the enrollee, the plan will automatically give a decision within 72 hours.

Representative — definition and authorization

DefinitionRepresentative — a person authorized to act on behalf of the enrollee to file an appeal when they are not the enrollee or the enrollee's prescriber.

Required documentationMust attach documentation showing authority to represent the enrollee, e.g., a completed Form CMS-1696 or a written equivalent, if not previously submitted at the coverage determination level.

When to complete representative sectionComplete the Representative information section only if the person making the request is not the enrollee or the enrollee's prescriber.

Help and contact for appointing representativeCall 1-833-230-2020 (TTY: 1-833-711-4711 or 711) for more information on appointing a representative.