After a Part D plan upholds a drug denial at redetermination, the enrollee, a representative or the prescriber can ask the Independent Review Entity to reconsider, and this CMS model form is the written request. The IRE, C2C Innovative Solutions, reviews the case outside the plan. Plans include the form with each adverse redetermination notice.
The enrollee, a representative or the prescriber completes it, and the prescriber may file without an appointment. The prescriber part covers prescriber information and a supporting statement, which matters most for expedited and exception requests.
Download the current version from the source each time; forms change without notice.
Request for Reconsideration of Medicare Prescription Drug Denial
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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C2C Innovative Solutions, Inc., the Part D Independent Review Entity, also called the Part D Qualified Independent Contractor. Requests reach it in writing by mail, fax or its online portal, not through the drug plan.
Within 65 calendar days from the date of the plan sponsor's redetermination decision notice. The IRE then decides within 72 hours for expedited requests or 7 calendar days for standard requests, and within 14 calendar days for payment requests.
Yes. An enrollee, the enrollee's representative or the enrollee's prescriber may request standard or expedited reconsideration after an unfavorable or partially favorable redetermination. For exception requests the prescriber's supporting statement is needed, and its absence can extend the decision timeframe by up to 14 days.