Request for a Medicare Part D appeal

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 is not 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 his or her behalf.

* Indicates a required field.

Member information
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Date of birth
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Submitter information

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

Medication information
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Call us toll-free at 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday.
(Oct. 1–March 31, seven days a week.)

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The information on this page was last updated on 10/1/2021.

Please refer to your Evidence of Coverage for more information. Fallon Health is an HMO plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal.