Get Because We

This guide provides clear and detailed instructions on how to complete the Because We form for requesting a redetermination of Medicare prescription drug denial. By following these steps, you will be able to efficiently fill out and submit the necessary information for your appeal.

Follow the steps to successfully complete the form

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the enrollee’s information. Include their full name, date of birth, address, city, state, zip code, phone number, and plan ID number.
3. If the person making the request is different from the enrollee, complete the section labeled 'Requestor's Information.' Include the requestor’s name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. Attach any representation documentation if the request is made by someone other than the enrollee or their prescriber. This may include an Authorization of Representation Form or an equivalent document.
5. Fill in the details of the prescription drug you are requesting. Include the name of the drug, its strength, quantity, and dose.
6. Indicate whether you have purchased the drug pending your appeal by checking 'Yes' or 'No.' If 'Yes,' fill in the date purchased and the amount paid. Attach a copy of the receipt.
7. Provide the name and telephone number of the pharmacy where the drug was purchased.
8. Complete the prescriber's information section. Enter the prescriber's name, address, city, state, zip code, office phone, fax number, and office contact person.
9. If you believe that waiting 7 days for a standard decision could seriously harm your health, check the box indicating this situation for expedited decisions.
10. Explain your reasons for appealing in the designated space. If necessary, attach additional pages and any supporting documents, including statements from the prescriber and relevant medical records.
11. Sign the form at the designated line and include the date of signing.
12. After completing the form, review all fields for accuracy, then save your changes, download, print, or prepare to share the form as needed.

Complete your appeal request online today to ensure your voice is heard.