Request Appeal for Drug Coverage

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.

Because we, Fidelis Care, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for redetermination (appeal) of our decision. You may ask for a redetermination after the date of our Notice of Action.

A Medicaid Medication Appeal Request (PDF) may be faxed to us at to 1-888-865-6531.

Expedited appeal requests can be made by phone at 1-866-800-6111.

Enrollee’s Information

First Name

Last Name

ID Number

Date of Birth

Enrollee’s Contact Information

Email Address

Phone Number

Street Address

Zip Code

City

State

Requestor’s Contact Information

Complete the following section ONLY if the person making this request is not the enrollee:

First Name

Last Name

Relationship to Enrollee

Phone Number

Street Address

Zip Code

City

State

Attach documentation showing the authority to represent the enrollee and enter a brief explanation below. For more information on appointing a representative contact your plan.

Prescription Drug Information

Name of Drug and Strength

Quantity Requested per Month

Dose

Check if you purchased the drug pending appeal

If "Yes":

Date Purchased

Amount Paid & Attach Receipt

Pharmacy Name

Pharmacy Phone Number

Prescriber’s Information

First Name

Last Name

Street Address

Zip Code

City

State

Phone Number

Fax Number

Important Notes: Expedited Decision

If you or your prescriber believe that waiting for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting could seriously harm your health, we will automatically give you a decision. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

CHECK THIS BOX IF YOU BELIEVE YOU NEED AN EXPEDITED DECISION.
If you have a supporting statement from your prescriber, attach it to this request.

Please explain your reasons for appealing. Enter any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Action.

Signature of person requesting the appeal (the enrollee, the enrollee's prescriber, or representative) and date are required upon submission.

Signature

Date

Print Form

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Y0020_WCM_164006E_M Last Updated On: 10/1/2024

Request Appeal for Medicaid Drug Coverage

Who May Make a Request

Please correct the following errors:

Please correct the following errors

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Information

Prescriber’s Information

Important Notes: Expedited Decision

Need help? We're here for you.

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Request Appeal for Medicaid Drug Coverage

Who May Make a Request

Please correct the following errors:

Please correct the following errors

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Information ?

Prescriber’s Information

Important Notes: Expedited Decision

Need help? We're here for you.

Prescription Drug Information