Request For Redetermination Of Medicare Prescription Drug Denial Part D Reconsideration Form

User Manual: Part-D-Reconsideration-Form

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Request for Redetermination of Medicare Prescription Drug Denial
Because we 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 our
Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form
may be sent to us by mail or fax:
Address:
GuildNet Gold Plus FIDA Plan
Attn: Grievance and Appeals
PO Box 2807
New York, NY 10116-2807

Fax Number:
1-212-510-5320

You may also ask us for an appeal through our website at www.guildnetny.org.
Expedited appeal requests can be made by phone at 1-866-557-7300.
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.
Participant’s Information
Participant’s Name

Date of Birth

Participant’s Address
City

State

Zip Code

Phone
Participant’s Plan ID Number
Complete the following section ONLY if the person making this request is not the participant:
Requestor’s Name
Requestor’s Relationship to Participant
Address
City

State

Zip Code

Phone
Representation documentation for appeal requests made by someone other than participant or
the participant’s prescriber:
Attach documentation showing the authority to represent the participant (a completed
Authorization of Representation Form CMS-1696 or a written equivalent) if it was not
submitted at the coverage determination level. For more information on appointing a
representative, contact your plan or 1-800-Medicare.
H0811_GN143_Part D Redetermination_GN Approved

Prescription drug you are requesting:
Name of drug:

Strength/quantity/dose:

Have you purchased the drug pending appeal? ☐ Yes
If “Yes”:
Date purchased:

☐ No

Amount paid: $

(attach copy of receipt)

Name and telephone number of pharmacy:

Prescriber's Information
Name
Address
City
Office Phone

State

Zip Code
Fax

Office Contact Person
Important Note: Expedited Decisions
If you or your prescriber believe that waiting 7 days 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 7 days could seriously harm your health, we will automatically
give you a decision within 72 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.
☐ CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS
If you have a supporting statement from your prescriber, attach it to this request.
Please explain your reasons for appealing. Attach additional pages, if necessary. 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.

Signature of person requesting the appeal (the participant, or the participant’s prescriber or
representative):
Date:

GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New
York State Department of Health (Medicaid) to provide benefits of both programs to Participants
through the Fully Integrated Duals Advantage (FIDA) Demonstration.
Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time
throughout the year and on January 1 of each year.
You can get this information for free in other languages. Call 1-800-815-0000 (TTY 711), Monday
through Sunday 8am to 8pm. The call is free.
Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/
TDD al 711, de lunes a domingo de 8am a 8pm. La llamada es gratis.
The State of New York has created a participant ombudsman program called the Independent
Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any
services offered by GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800
or online at icannys.org.
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Create Date                     : 2014:12:17 14:11:40-05:00
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Subject                         : Prescription Drug Denial Form
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Title                           : Request for Redetermination of Medicare Prescription Drug Denial
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