Please use this form to start a Medicare Part D appeal.

Once we receive this request, a form will be sent to the member or member's representative for a signature in order to process the appeal. If the person filing this appeal isn't the prescribing provider or not an authorized representative of the member, an Appointment of Representative form will be sent to the member to authorize the representative to file on their behalf.

* Indicates a required field.

Member information

First name

Last name

Date of birth

Address 1

Address 2

City

State

ZIP code

Phone number

Submitter information

If the person filing this appeal is not the member, please complete the section below.

Relationship to member

First name

Last name

Address 1

Address 2

City

State

ZIP code

Phone number

Medication information

Name of prescription medication that was denied

Reason for appealing

H9001_270027_M
H8928_270025_M Accepted 09302026
The information on this page was last updated on 10/1/2026.

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Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse.
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Multi-language Interpreter Services (H8928_221330_C, pdf)
Notice of inclusion resources (pdf)

For information in other languages:

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Anonymous Compliance Hotline: Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse. You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.