Request for a Medicare Part D appeal

Please use this form to initiate 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, a "Personal Representative Authorization–Filing an Appeal" form will be sent to the member to authorize the representative to file on his or her behalf.

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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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Please refer to your Evidence of Coverage for more information.

Fallon Health is an HMO/HMO-POS plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal.

H9001_F_2017_21 Approved 10172016
H9001_N_2017_16 Approved 10142016
The information on this page was last updated on 10/1/2016.

Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)