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Step 3: Decide which plan is best for you, and join.

If you ask for a coverage determination and the plan decides against you, you can appeal the decision. There are 5 levels of appeal available to you. You must follow the order listed below:

1. Appeal through your plan.

The first level of appeal is called a "redetermination." You must request this appeal within 60 calendar days from the date of the coverage determination notice. Only you or your appointed representative can file a standard request. Standard requests must be made in writing unless your plan allows you to file a request by telephone. You, your appointed representative, or your doctor can ask your plan for an expedited redetermination. Expedited requests can be made in writing or by telephone. Your request will be expedited if your plan determines, or your doctor tells your plan, that your life or health may be seriously jeopardized by waiting for a standard decision. Any unfavorable coverage determination decision you get from your plan will tell you how to file this appeal. Once your plan gets your request for an appeal, the plan has 7 calendar days (for a standard request for coverage or for a request to pay you back) or 72 hours (for an expedited request for coverage) to notify you of its decision.

A written appeal request should include the following:
  • Your name, address, and the health insurance claim (HIC) number shown on your Medicare card
  • The name of the prescription drug you want your plan to cover
  • Reasons why you are appealing and any supporting documentation that you believe may help your case
  • Your signature or the signature of your appointed representative


Once your plan gets your request for an appeal, the plan has 7 calendar days (for a standard request for coverage or for a request to pay you back) or 72 hours (for an expedited request for coverage) to notify you of its decision.


2. Review by an Independent Review Entity

If you disagree with the plan’s redetermination, you or your appointed representative can request a review by an Independent Review Entity (IRE) called a "reconsideration." The request must be filed in writing within 60 calendar days from the date of the plan’s redetermination decision. Your request must be sent to the IRE at the address or fax number listed in the plan’s redetermination decision. This decision letter will be mailed to you and will fully explain how to file this appeal. The plan will also send you a "Request for Reconsideration" form that you can use to request a reconsideration. If you don’t get this form, call your plan and ask for it. You can also get this form by visiting www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp on the web.

You or your appointed representative may request either a standard or expedited reconsideration. Your reconsideration request will be expedited if the IRE determines, or your doctor tells the IRE, that your life or health may be seriously jeopardized by waiting for a standard decision.

Important: If you are asking the IRE for an exception and the plan didn’t previously process your request as an exception, you will need a supporting statement from your doctor explaining why you need the drug you are requesting. Check with the IRE to find out if the supporting statement is required, and if it must be in writing. If a supporting statement is required, the IRE’s decision-making time period begins once it gets the statement.

Once the request for review (and the supporting statement, if required) has been filed, the IRE has 7 days (for a standard request for coverage or for a request to pay you back) or 72 hours (for expedited requests for coverage) to notify you of its decision.


3. Hearing with an Administrative Law Judge

If you disagree with the IRE’s decision (reconsideration notice), you or your appointed representative can request an Administrative Law Judge (ALJ) hearing. You or your appointed representative must make the request in writing within 60 calendar days from the date of the IRE’s reconsideration notice. The request must be sent to the location listed in the IRE’s reconsideration notice that is mailed to you. To get an ALJ hearing, the projected value of your denied coverage must meet a minimum dollar amount (you may be able to combine claims to meet the minimum dollar amount). The IRE’s notice will include this amount.


4. Review by the Medicare Appeals Council

If you disagree with the ALJ’s decision, you or your appointed representative can request a review by the Medicare Appeals Council (MAC). The request must be sent to the MAC in writing within 60 calendar days from the date of the ALJ’s decision. You must send your request to the location listed in the ALJ’s decision that is mailed to you.


5. Review by a Federal court

If you disagree with the MAC’s decision, you or your appointed representative can request a review by a Federal court. The request must be filed in writing within 60 calendar days from the date you received the MAC’s decision. You must send your request to the location specified in the MAC’s decision. To receive a review by a Federal court, the projected value of your denied coverage must meet a minimum dollar amount. The MAC’s decision will include the amount.

When you join a Medicare drug plan, the plan will send you information about the plan’s appeal procedures. Read the information carefully and keep it where you can find it when you need it. Call your plan if you have questions.



(Primary Source: Centers for Medicare and Medicaid Services - Your Guide to Medicare Prescription Drug Coverage 2008. This content may have been enhanced by Q1Group LLC to include further examples, explanations, and links.)


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