Appeal Rights

Request for Redetermination of Medicare Prescription Drug Denial

If we deny 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 Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Appeal Process

To appeal a decision, please follow these steps:

• Download the Request for Redetermination of Medicare Prescription Drug Denial form
• Complete the form and either mail or fax it to Prominence Health Plan at:

Prominence Health Plan
c/o MedImpact
10181 Scripps Gateway Court
San Diego, CA 92131

Fax Number: 858-790-6060 — standard and expedited appeals

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.

If you have questions, please call 844-587-7389 (TTY: 711).

Y0109_WEBSITE20