Request for a Medicare Part D appeal

Please use this form to start 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 form will be sent to the member to authorize the representative to file on his or her behalf.

* Indicates a required field.

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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Call us toll-free at 1-800-325-5669 (TRS 711), Monday-Friday, 8 a.m.-8 p.m.
(Oct. 1-March 31, seven days a week.)

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The information on this page was last updated on 10/1/2019.

Please refer to your Evidence of Coverage for more information. Fallon Health is an HMO plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal.