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Medicare Part D Redetermination Request Form

When a Medicare Part D plan denies coverage or payment for a drug, the first appeal is a redetermination by the plan, and this CMS model form is the standard written request. Prescribers meet it because they can file for the patient and explain why the drug is needed. Plans include it with denial notices and decide within 7 calendar days, or 72 hours if expedited.

Who completes it

The enrollee, a representative or the prescriber completes it, and the prescriber can file without being appointed as the enrollee's representative. The prescriber section covers prescriber details and the explanation of why the drug should be covered, with a signature when the prescriber files.

Submitting and payment

How to submit it
Send it to the Part D plan by fax or mail, using the contact details the plan fills in, within 65 calendar days of the coverage determination notice. Expedited requests may be made by phone, and some plans accept oral standard requests.
Who pays
When the enrollee asks to be paid back for a drug already bought, the plan must send its decision, and any payment due, within 14 calendar days.

Good to know

  • Revised December 2024 for use from January 1, 2025. CMS posts it as a ZIP file containing Word and PDF versions plus instructions.
  • Expedited redeterminations are decided within 72 hours; if the plan gives verbal notice, it must mail the written decision within 3 calendar days.
  • If the plan upholds the denial, the next level is reconsideration by the Part D Independent Review Entity, using CMS's separate Request for Reconsideration form.
  • Representatives other than the prescriber need an Appointment of Representative (Form CMS-1696) or a written equivalent submitted with the request.

Get the official form

Download the current version from the source each time; forms change without notice.

Request for Redetermination of Medicare Prescription Drug Denial

Official page

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Can a doctor file a Medicare Part D redetermination?

Yes. CMS allows the enrollee's prescriber to request a coverage determination, redetermination or IRE reconsideration without being an appointed representative. The prescriber completes the prescriber information and the explanation of why the drug should be covered, and signs the request.

What is the deadline for a Part D redetermination?

The request must be filed within 65 calendar days from the date of the plan's coverage determination notice. The plan then decides within 7 calendar days for a standard request, 72 hours for an expedited request, and 14 calendar days for a payment request.

Where do I get the Part D redetermination form?

Plans must include the model form with each denial notice and fill in their own address and fax. CMS also posts it on its Part D appeals forms page as a ZIP file with Word and PDF versions and instructions.