Get Part D Drug Case Transmittal Form - Medicare Part D Appeals Home

This guide provides users with clear and systematic instructions for completing the Part D Drug Case Transmittal Form needed for Medicare Part D appeals. With careful attention to detail, you can efficiently navigate each section of the form online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the appeal information. Check the appropriate box under 'Priority' to indicate whether the appeal is Expedited or Standard. Also, specify the 'Appeal Type' and whether the case is 'Out of Compliance'.
3. Provide the requestor's name, the enrollee's name, and their health insurance card number or Medicare claim number. Include the date of birth, address, and telephone number of the enrollee.
4. Indicate whether the enrollee requires the Reconsideration Notice in a language other than English by selecting 'Yes' or 'No'. If 'Yes', specify the required language.
5. In the Part D Plan Information section, indicate the Plan Type by selecting from the options provided (PDP, MMP, MA-PD). Enter the Plan Contract Number and the 4-digit C.M.S. Plan Number.
6. Fill in the Plan Identification Number, Formulary Name/Formulary ID, and provide contact details including the Plan Contact Name, Title, Phone Number, Email Address, and Plan Address.
7. If applicable, list the Representative's details (Name, Address, Phone Number, Email Address). Make sure to check the plan attestation for representative appeals.
8. Fill out the Plan Level 0: Coverage Determination section. Provide the Date Coverage Determination was requested, and indicate if the Appellant asked the plan to expedite the request.
9. Provide the Drug Benefit in Dispute section by entering the name of the drug, dosage, amount, refill number, and specify whether it's a Brand or Generic request.
10. If there are multiple drugs in dispute, complete a separate version for each drug.
11. In the Exhibits section, label applicable documents accordingly and attach them in order. Ensure you include all procedural and evidentiary documents as outlined.
12. Review all the information filled out for accuracy. Once complete, proceed to save your changes, download, print, or share the form as needed.

Start filling out your Part D Drug Case Transmittal Form online today.