Tip for CMS model redetermination form

Request an expedited redetermination if you urgently need the medication

Tip for CMS model redetermination form

Submit new clinical evidence that was not part of the original determination

Tip for CMS model redetermination form

The plan's reviewer must be a physician — not the same person who made the initial denial

Medicarehard

Part D Redetermination Request

CMS model redetermination form · CMS

Level 1 appeal of a Part D coverage determination denial. Plan must decide within 7 days (standard) or 72 hours (expedited).

Form Details

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Where to Submit This Form

📬

Mail to your Part D plan

Address is on the coverage determination denial notice.

📠

Fax to your Part D plan's appeals department

Fax number is on the denial notice.

Filing Deadline

60 days from the date of the unfavorable coverage determination notice.

Required Attachments

📎 Copy of the unfavorable coverage determination
📎 Prescriber's supporting statement with clinical rationale
📎 Updated medical records and documentation of failed alternatives
📎 Peer-reviewed literature supporting the requested drug (if applicable)

Processing Time

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

What Happens Next

The plan must conduct a full and fair review by a physician reviewer. If the denial is upheld, the case is automatically forwarded to the IRE.

Tips for This Form

✓ Request an expedited redetermination if you urgently need the medication
✓ Submit new clinical evidence that was not part of the original determination
✓ The plan's reviewer must be a physician — not the same person who made the initial denial
✓ If upheld, the automatic IRE forwarding means you do not need to take any additional action to continue the appeal

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