Coverage Redetermination Form
Request for redetermination of Medicare prescription drug denial
Because we, Mercy Care Advantage (HMO SNP) denied 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. This form may be sent to us by mail or fax:
Mercy Care Advantage
Attn: Part D Appeals
4500 E. Cotton Center Blvd.
Phoenix, Arizona 85040
Attn: Part D Appeals-Pharmacy Department
Mercy Care Advantage accepts oral appeal requests. You can request a standard or expedited oral appeal by calling Member Services at 1-877-436-5288 or 602-586-1730, 8:00 a.m. - 8:00 p.m., 7 days a week. TTY/TDD users should call 711.
You may also ask us for an appeal through our website or by e-mailing email@example.com.
Fill out the Coverage Redetermination Form online.
You can also fill out this form in Spanish.
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.