If your Medicare Prescription Drug Plan denies a request for drug coverage or reimbursement for a drug under Medicare Part D, you have the right to appeal if you disagree with the Plan's decision.
The Evidence of Coverage Booklet
As a Medicare Prescription Drug Plan member, you will receive an “Evidence of Coverage,” or EOC, booklet. The EOC contains information about your right to ask the Plan to provide or pay for a medication that you and your prescriber (the doctor who prescribed the medicine) think is medically necessary.
Always review your Plan materials or contact your Plan for the latest information on your appeal rights, including who can be your representative, where to send your request, what the filing deadlines are and if there are any minimum dollar amount requirements, as these are always subject to change.
Requesting a Coverage Determination From Your Plan
If your pharmacist notifies you that your Plan will not cover a drug, you or your prescriber may ask for a written explanation, called a "coverage determination," from your Plan. You may also pay for the prescription and then request reimbursement from the Plan through a coverage determination. You must have a written denial from your Plan (a coverage determination) before you can proceed with an appeal.
If your pharmacist can’t fill your prescription, you should receive a notice explaining how to contact your Plan so you can make your request. Ask your pharmacist for a copy of the notice if it is not offered.
How to Make a Standard Request
You or your prescriber may call or write to your Plan to make a standard request if you are asking for a drug to be covered. If you are requesting reimbursement for a drug you already bought, your Plan may require you or your prescriber to make a standard request in writing.
Your Plan has 72 hours from receipt of your standard request to notify you of its decision regarding coverage or reimbursement.
You or your prescriber may also request an expedited or fast request if your doctor notifies the Plan that your health or life may be at risk by waiting. Your Plan has 24 hours to notify you of its decision from receipt of an expedited request.
Exception to Formulary or Plan Rule
If you are requesting an exception, which is also a type of coverage determination, you must submit your doctor’s medical statement explaining why the exception should be approved. Here are some examples of when you might ask for an exception.
- Your doctor has prescribed a drug that isn’t on the Plan’s formulary
- Your doctor believes that a Plan rule, such as prior authorization, should be waived, or
- You think you should pay less for a more expensive drug because you or your doctor believe that a less expensive drug is not appropriate for your condition.
Level 1 Appeal: Request for Redetermination by the Plan
The first level of review (appeal) of a Plan’s coverage determination is called a request for redetermination. You must file this request in writing within 60 days of receiving a coverage determination/denial of coverage letter, unless your Plan accepts requests by telephone. The Plan’s coverage determination will give you the reason(s) for the denial and instructions on how to file a Level 1 appeal.
The Plan will notify you of a standard decision in seven days or an expedited decision in 72 hours.
Level 2 Appeal: Request for Reconsideration by an Independent Review Entity (IRE)
If the Level 1 decision is not in your favor, you can file a request for reconsideration by an Independent Review Entity (IRE) within 60 days. Follow the instructions in the Plan’s redetermination decision for filing a Level 2 appeal.
You will generally receive the IRE’s decision within seven days of submitting a standard request for reconsideration. If your request is expedited, the IRE has 72 hours to notify you of its decision.
Level 3 Appeal: Request for Administrative Law Judge Hearing
If the Level 2 decision was not decided in your favor, you may file a written Level 3 request for hearing before an administrative law judge, or ALJ, within 60 days. Follow the instructions in the IRE’s decision for requesting a Level 3 appeal.
The projected value of your prescription coverage must meet a minimum amount in controversy for an ALJ hearing. There are several ways to meet this minimum amount. The amount in controversy requirement changes annually and will be indicated in IRE’s decision, or you may call you Plan or review your Plan materials for this information.
Most ALJ hearings are now held by telephone or by videoconference from a remote hearing site. But if you can show the ALJ that “good cause” exists for you to appear in person, you can have an in-person hearing at one of four field offices. In some cases, the ALJ may decide to skip the hearing and may the case “on-the-record,” when the evidence in your claim file alone supports a decision in your favor.
You should consider seeking legal assistance through a Medicare lawyer or elder care lawyer before requesting an ALJ hearing.
Level 4 Appeals: Medicare Appeals Council Review
If you disagree with the Level 3 ALJ decision, you have 60 days to file a written request for review by the Medicare Appeals Council (MAC). Follow the directions in the ALJ’s decision regarding how to file a request for a review by the Medicare Appeals Council.
You should not try to handle an Appeals Council review without a lawyer.
Level 5 Appeal: Federal District Court Civil Lawsuit
If you disagree with the MAC’s Level 4 decision, you have 60 days to file a civil action in your local federal district court. You must also meet the minimum dollar amount requirement. The MAC’s decision will give you information about filing a civil action.
As this is a formal court proceeding, you'll need to hire a Medicare or Social Security lawyer before filing a lawsuit. This is the last level of appeal available to you.
Where to Get Additional Information
For more information on the Medicare Part D appeals process, go to the Medicare website's Part D appeals area, the Office of Medicare Hearings & Appeals website, or the Departmental Appeals Board website.
Or, to have a lawyer answer your Medicare Part D questions and/or handle all your appeals for you, contact a Social Security lawyer here.