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Request for a Redetermination of a Denial of Prescription Drug Coverage

Because we, University of Maryland Health Advantage, 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 Medicare Prescription Drug Coverage to  ask us for a redetermination.  This form will be sent to us when you complete the form and click the "Send Request" button at the bottom of the form.

You may also ask us for an expedited appeal request by checking the appropriate box on the form, or by phone using the telephone number printed on your ID card.

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.

This page allows you to submit a redetermination (appeal) online if you want us to reconsider and an adverse coverage determination about Part D prescription benefits being covered or what we will pay for a prescription drug.

Please note that fields marked with a * on the form are required fields.

Please read through the forms before you complete it to make sure you have all the information you need. If you have any questions, please contact Member Services at the number listed on your ID card.

It is very important that the Request for Redetermination (Appeal) be filled out completely and accurately for the Part D Appeals & Grievance Unit to process your request. Please contact Member Services at the number listed on your ID card if you have any questions.