Forms

What's New

12/12/24: The following model forms have been updated.  Both Microsoft Word and PDF formats are available in the Downloads section at the bottom of this page.

The Request for a Medicare Prescription Drug Coverage Determination is available for immediate use.

The Request for a Medicare Prescription Drug Redetermination and Request for Reconsideration of Medicare Prescription Drug Denial Forms are available for use beginning 01/01/2025. Plan Sponsors should continue to use the current model forms through December 31, 2024.

Overview

This section provides specific information of particular importance to beneficiaries receiving Part D drug benefits through a Part D plan.  Included in the "Downloads" section below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes (with the exception of the Appointment of Representative form, which has a link in the "Related Links" section below).

Appointment of Representative Form CMS-1696

If an enrollee would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on his or her behalf, the enrollee and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. (See the link in "Related Links" section). The enrollee's prescribing physician or other prescriber may request a coverage determination, redetermination or IRE reconsideration on the enrollee's behalf without having to be an appointed representative.

Request for a Medicare Prescription Drug Coverage Determination

An enrollee, an enrollee's representative, or an enrollee's prescriber may use this model form to request a coverage determination, including an exception, from a plan sponsor.

Request for a Medicare Prescription Drug Redetermination

An enrollee, an enrollee's representative, or an enrollee's prescriber may use this model form to request a redetermination (appeal) from a plan sponsor.

Request for Reconsideration of Medicare Prescription Drug Denial

An enrollee or an enrollee's representative may use this model form to request a reconsideration with the Independent Review Entity. You may download this form by clicking on the link in the "Downloads" section below.

Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal

An enrollee or an enrollee's representative may use the form “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100” to request an ALJ hearing, or to request a review of an Independent Review Entity's dismissal. A link to the OMHA-100 form and all forms needed to file an appeal with the Office of Medicare Hearings and Appeals (OMHA) can be found in Related Links at the bottom of the page.