Medicare Part D Benefits File an Appeal

If you were recently denied coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal). You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. Please complete the form below to file an appeal for your Medicare Part D Benefits coverage.

Enrollee's Information

Enrollee's Name Date of Birth (mm/dd/yyyy) Enrollee's Address City State ZIP Code Phone Enrollee's Plan ID Number

Complete the following section ONLY if the person making this request is not the enrollee. *VillageHealth may reach out to you for documentation showing the authority to represent the enrollee.**

Requestor's Name Requestor's Relationship to Enrollee Address City State ZIP Code Phone

Prescription drug you are requesting:

Name of drug: Strength/quantity/dose

Have you purchased the drug pending appeal?

If Yes, date purchased: If Yes, amount paid: If Yes, name and telephone number of pharmacy:

Prescriber's Information

Name Address City State ZIP Code Phone Fax Office Contact Person

Important Note: Expedited Decisions

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS.

Reason for Appealing

Please explain your reasons for appealing.

If you have a supporting statement from your prescriber, please print out the Medicare Part D Benefits appeals form and submit it with the statement. CLICK HERE for the appeals form.

Please print and mail your appeal form along with all supporting documentation via FAX to: 562-989-0958 or by mail to:

VillageHealth
Attention: Grievance and Appeals Department
PO Box 22644
Long Beach, CA 90801-5644

**VillageHealth may reach out to you for documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent).