Request an expedited review if you are currently taking the medication and it is about to run out

Your prescriber can request a coverage determination on your behalf

If your plan requires step therapy, document all prior drugs tried and why they did not work

Medicareeasy

Important Message from Medicare (IM)

CMS-10065 · CMS

Notification given within 2 days of hospital admission informing patients of their discharge rights and the appeal process.

Form Details

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Filled by: patient
Frequency: per incident

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Where to Submit This Form

📬

Mail to your Medicare Advantage plan or Part D plan

Send to the address on your denial notice or the plan's appeals department.

📠

Fax to your plan's coverage determination department

Fax number is on the denial or coverage determination notice.

Filing Deadline

60 days from the date of the initial coverage determination you want to appeal.

Required Attachments

📎 Copy of the initial coverage determination (denial notice)
📎 Prescriber's supporting statement explaining medical necessity
📎 Relevant medical records and diagnosis information
📎 Documentation of prior medications tried and failed

Processing Time

Standard Part D: 7 days. Expedited: 72 hours if delay could seriously harm your health.

What Happens Next

The plan must issue a redetermination decision. If denied again, the case is automatically forwarded to an Independent Review Entity (IRE).

Tips for This Form

✓ Request an expedited review if you are currently taking the medication and it is about to run out
✓ Your prescriber can request a coverage determination on your behalf
✓ If your plan requires step therapy, document all prior drugs tried and why they did not work
✓ Ask your prescriber for samples to bridge the gap while the appeal is being processed

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