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REQUEST FOR REDETERMINATION (AN "APPEAL") OF A COVERAGE DETERMINATION FOR PRESCRIPTION DRUG(S)

You have the right to request a reconsideration (an "appeal") of a coverage determination we have previously made, even if only part of our decision was not what you requested. Timeframe to File Your Appeal: You must make your appeal request in writing within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Who Can File An Appeal: A request for an appeal can be made by you, or on your behalf by your appointed representative or your prescribing physician. What Is A Fast Appeal?: If you are appealing a decision we made about a drug you have not yet received, you can get a fast decision. (You cannot get a fast decision if you are asking us to pay you back for a drug you are already bought.) You can get a fast decision only if using the standard deadlines listed below could cause serious harm to your health or hurt your ability to function. If your doctor or other prescriber tells us that your health requires a "fast decision," we will automatically agree to give you a fast decision. If you ask for a fast decision on your own (without your doctor's or other prescriber's support), we will decide whether your health requires that we give you a fast decision. If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it. If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by the Independent Review Organization (IRE). The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with our plan. We will notify you if we have to automatically forward your request to the IRE. What Is A Standard Appeal ?: If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. We will notify you if we have to automatically forward your request to the IRE. How Can I Save Time And Make Sure All Important Information Is Submitted With My Appeal Request? As a part of the Appeals process, we need to make sure we have all important information from you and your prescribing physician so we can make our decision. By having your prescribing physician complete one section of the attached form, we can save time in the standard appeal process for you. If your prescribing physician does not complete this section, we will reach out to your prescribing physician for the additional information. Once you have completed the attached form, please mail or fax it along with any supporting documentation to the Plan at the address or fax number below. Y0022_10ALL_557_pdp1appl CMS Approval Date: 06/30/2010

Plan Name

Address

Phone/TDD

th

Fax

Advantra Texas (PPO)

8320 Ward Parkway, 4 Floor Kansas City, MO 64114

800-536-6167 711 Telecommunications Relay Service. 800-708-9355 x1910 711 Telecommunications Relay Service. 866-784-4918 711 Telecommunications Relay Service.

816-460-4952

Advantra North Carolina (PPO) Altius Health Plans, Inc.(Advantra HMO/PPO UT/WY) Coventry Health Care of Georgia, Inc. (Advantra HMO) Coventry Health Care of Iowa, Inc. (Advantra HMO/PPO) (IA/SD) Coventry Health Care of Kansas, Inc. (Advantra HMO/PPO) Coventry Health Care of Nebraska, Inc. (Advantra HMO/PPO) Group Health Plan, Inc. (Advantra/Gold Advantage HMO) Health America of Pennsylvania (Advantra HMO/PPO PA/OH) Personal Care of Illinois, Inc. (Advantra PPO) Summit Health (HMO))

2801 Slater Road, Ste 200, Morrisville, NC 27560 10421 Jordan Gateway, Suite 400, South Jordan, UT 84095 1100 Circle 75 Parkway, Suite 1400, Atlanta, GA 30339

866-799-9451

801-323-6050

866-613-4977 711 Telecommunications Relay Service. 800-470-.6352 4320 114th Street, Urbandale, IA 50322 711 Telecommunications Relay Service. 8320 Ward Parkway, Kansas 800-727-9712 City, MO 64114 711 Telecommunications Relay Service. 800-.228-0286 15950 West Dodge Road, Omaha NE 68118 711 Telecommunications Relay Service. 550 Maryville Centre Drive, 800-.743-3901 Suite 300,St. Louis, MO 711 Telecommunications 63141 Relay Service. 3721 TecPort Drive, P.O. Box 67103, Harrisburg, PA 17106-7103 2110 Fox Drive, Ste. A, Champaign, IL 61820 1340 Concord Terrace Sunrise, FL 33323 1340 Concord Terrace Sunrise, FL 33323 1340 Concord Terrace Sunrise, FL 33323 800-290-0190 711 Telecommunications Relay Service. 866-784-4916 711 Telecommunications Relay Service. 800-847-3995 711 Telecommunications Relay Service. 866-847-8235 711 Telecommunications Relay Service. 800-441-5501 711 Telecommunications Relay Service.

866-823-5234

515-327-0612

816-460-4952

866-769-2399

314-506-1655

717-541-5738

800-698-2043

954-858-3437

Vista Healthplan (HMO FL) Vista Healthplan of South Florida (HMO FL)

954-858-3437

954-858-3437

REQUEST FOR REDETERMINATION (AN "APPEAL") OF A COVERAGE DETERMINATION FOR PRESCRIPTION DRUG(S) FORM

Member Name:________________________________________________ Member ID Number:___________________________________________ Date of Birth: _______________ Member Medicare Number (on Red, White, Blue Card): _______________________________ Requestor's Name (if not Member): ___________________________________________ Relationship to Member: ________________________________________ (Must attach document that shows Authority to represent the member, if other than prescribing Physician) Member/Requestor's Address: ____________________________________________________ _____________________________________________________ City State Zip Code Member/Requestor's Phone Number: ___________________________________

Please provide the name and strength of the prescription drug for which you are requesting coverage/payment: __________________________________________________________________ Please state below the reasons why you do not agree with the Plan's decision on your request. If you need more room, please use the blank space on the reverse side of this form or attach additional paper if necessary. I do not agree with the Plan's decision because: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________

To be completed by Prescribing Physician:

The Plan provided a list of alternative medications when the original coverage determination was made. Please provide clinical documentation as to why the listed alternative(s), where applicable, would be inappropriate and/or documentation that they have been less effective than the requested medication in this patient. In addition, please provide pertinent laboratory values and/or office documentation to support the members diagnosis if necessary. If you need more room, please write on the blank space on the reverse side of this form or attach additional paper if necessary. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________

Please submit any additional written documentation that you feel supports your request. (Attach such documents to this form.)

_________________________________________________ Signature of Member/Requestor

__________________ Date

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