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
*
*
Date of birth
*
*
*
*
*
Submitter information

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

Medication information
*
*
Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. 
(Oct. 1–March 31, seven days a week.)

H9001_190047_C
H9001_190049_C
The information on this page was last updated on 10/1/2018.

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