FCHP - Request for a Medicare Part D appeal

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, an Appointment of Representative form will be sent to the member to authorize the representative to file on their behalf.

* Indicates a required field.

Member information

First name

Last name

Date of birth

Address 1

Address 2

City

State

ZIP code

Phone number (with area code)

Submitter information

If the person submitting this appeal is not the member, please complete the section below.

Relationship to member

First name

Last name

Address 1

Address 2

City

State

ZIP code

Phone number (with area code)

Medication information

Name of prescription medication that was denied

Reason for appealing

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

H8928_240094_C
H9001_240093_C
The information on this page was last updated on 10/1/2023.

Please refer to your Evidence of Coverage for more information.

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One Chestnut Place, 10 Chestnut Street, Worcester, MA 01608
1-888-340-5504 (TRS 711) | MedicareSalesOperations@fallonhealth.org

Anonymous Compliance Hotline: 1-888-203-5295 (toll-free)
Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse.
You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.

Multi-language Interpreter Services (H8928_221330_C, pdf)
Notice of inclusion resources (pdf)

For information in other languages:

One Chestnut Place, 10 Chestnut Street, Worcester, MA 01608
1-800-868-5200 (TRS 711), Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

Notice of inclusion resources (pdf)

For information in other languages:

English	Tiếng Việt	Français	Polskie
Español	Pусский	Italiano	हिंदी
Português	العربية	한국어	ગુજરાતી
中文	ភាសាខ្មែរ	ελληνικά	ລາວ

Anonymous Compliance Hotline: Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse. You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.