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Because we, Virginia Premier CompleteCare (Medicare-Medicaid Plan), a Commonwealth Coordinated Care Plan, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
Who May Make a Request: Your prescriber may ask us for an appeal on your behalf. If you want another individual, such as a family member or friend, to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.
Note: All fields marked with an asterisk (*) are required.
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