Request for a Medicare Part D appeal

Please use this form to initiate 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–Filing an Appeal" form will be sent to the member to authorize the representative to file on his or her behalf.

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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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Fallon Health Weinberg is an HMO plan with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Fallon Health Weinberg depends on contract renewal.

H2470_W_2017_7 Approved 10182016
The information on this page was last updated on 10/1/2017.

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Information before enrolling:
1-855-561-7248 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

Customer Service:
1-855-561-7247 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)