Provider Appeal - Part D (Prescription Drug) Form

This form is for providers to request an appeal after they receive an adverse Part D (Drug) coverage decision (PA, Claim). Supporting documentation must be uploaded; this may include, but is not limited to: medication history, diagnostic workup, lab results, chart notes, etc.

Who May Request a Level 1 Appeal

Part D Appeal
The enrollee’s prescriber (MD, DO, NP, PA) acting on behalf of the enrollee or staff of prescriber’s office acting on said prescriber’s behalf (e.g., request is on said provider’s letterhead or otherwise indicates staff is working under the direction of the provider).

Important Note for Expedited Decisions

Medicare Part D Drug - If you believe that waiting 7 days for a standard prescription drug decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision.

Are you requesting for a decision within 72 hours?

Expedited appeal requests can also be made by phone at: 1-877-672-8620 (TTY 711), daily from 8 a.m. to 5 p.m. PST.

Provider/Physician Information

Provider Full Name *

Street Address *

Street Address Line 2

City *

Zip Code *

Phone Number *

Fax # *

Email *

Drug Name *

Drug Dosage/Strength *

Duration of Drug That Was Denied

Reason for Appeal *

Date of Service (if applicable)

Date Drug Was Denied

Date of Decision Notice

Have the Member purchased the drug pending appeal? *

Yes
No
Unknown

Pharmacy Name

Pharmacy Address

Pharmacy Phone Number

PA Case # or Reference # *

Upload any supporting documentation

Patient Information

Patient Full Name *

Patient Member ID # *

Date of Birth *

Requestor's Full Name *

Provider Appeal - Part D (Prescription Drug) Form

Company

Resources

Compliance at ATRIO

Disclosures