Medicare Part D Benefits: File an Appeal

If you were recently denied coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal). You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. Please complete the form below to file an appeal for your Medicare Part D Benefits coverage.
Enrollee's Information
Please enter a 5 digit zip code.
Enter a 10-digit telephone number including area code.
Complete the following section ONLY if the person making this request is not the enrollee. *SCAN may reach out to you for documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent).
Please enter a 5 digit zip code.
Enter a 10-digit telephone number including area code.
Prescription drug you are requesting:
Have you purchased the drug pending appeal?
Prescriber's Information
Please enter a 5 digit zip code.
Enter a 10-digit telephone number including area code.
Important Note: Expedited Decisions

*If you believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

Reason for Appealing

If you have a supporting statement from your prescriber, please print out the Medicare Part D Benefits appeals form and submit it with the statement. CLICK HERE for the appeals form.

Please print and mail your appeal form along with all supporting documentation via FAX to: 562-989-0958 or by mail to:

SCAN Health Plan 
Attention: Grievance and Appeals Department
PO Box 22644
Long Beach, CA 90801-5644