Prescription Drug Assistance
November 23, 2005
Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
We are writing to you about your request for a review of our determination that you
will no longer be able to get help with your Medicare prescription drug plan costs.
Because you waited more than 10 days to ask for a review and did not have a good reason
for the delay, we must deny your request to get the same subsidy amount until we decide
You Asked For A Review Too Late
We sent you a letter on September 1, 2005 to tell you about our determination. The
letter explained that if you appealed in 10 days you would continue to get the same
subsidy amount until we decided your case. The 10 days started the day after you got
the letter. You asked for a review on September 25, 2005. This is after the 10-day
If You Have Any Questions
For information about Medicare prescription drug plans or other Medicare issues, visit
www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf
or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.
For information about the extra help with the costs related to Medicare prescription
drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 1-800-772-1213. If
you are deaf or hard of hearing, you may call our TTY number toll-free at 1-800-325-0778.
We can answer most questions by phone.
If you do call, please have this letter with you. It will help us answer your questions.
Determination Unit Reviewer