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Medicare Part D Benefits: File an Appeal

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 (a completed Authorization of Representation Form CMS-1696 or a written equivalent).
Prescription drug you are requesting:
Prescriber's Information
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.
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
Reason for Appealing