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

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.**

Prescription drug you are requesting:

Have you purchased the drug pending appeal?

Prescriber's Information

Important Note: Expedited Decisions

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

 

**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).