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Request for Reconsideration of Medicare Prescription Drug Denial

An enrollee or an enrollee's representative may use this model form to request a reconsideration with the Independent Review Entity

Issued by: Centers for Medicare & Medicaid Services (CMS)

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.