How to Appeal a Medicare Part D Coverage Decision

1. Appeal through your plan

The first level of appeal is called a "redetermination." The plan’s initial denial notice will explain how to file this appeal. You must request this appeal within 60 calendar days from the date on the coverage determination notice.

You, your doctor or other prescriber, or your representative may request a standard or expedited redetermination. Standard requests must be made in writing, unless your plan allows you to file a standard request by telephone. Your request will be expedited if your plan determines, or your prescriber tells your plan, that your life or health may be at risk by waiting for a standard decision. Your plan’s address and phone number is in your plan materials and will also be in any unfavorable coverage determination decision you get.

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

A written request to appeal must include the following:

• Your name, address, and the Medicare claim number (your Medicare number) shown on your Medicare card
  
  
• The name of the prescription drug you want your plan to cover
  
  
• Reasons why you are appealing
  
  
• Your signature or the signature of your representative

You should send any supporting documentation that you believe may help your case,including medical records, with your appeal request.

• Jump to CMS Medicare Part D Appeals Process Flowchart

2. Review by an Independent Review Entity (called a "reconsideration")

If your Medicare drug plan makes an unfavorable redetermination decision, it will send you a written decision. If you disagree with the plan’s redetermination, you can request a review by an Independent Review Entity (IRE).

Tip: If your plan issues an unfavorable redetermination, it should also send you a "Request for Reconsideration" form that you can use to ask for 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.

You or your representative must make a standard or expedited request 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. Your reconsideration request will be expedited if the IRE determines, or your prescriber tells the IRE, that your life or health may be at risk by waiting for a standard decision.

Once the request for review 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.

The Part D QIC received 20,733 reconsideration requests during calendar year 2009. It is a 25% increase in the number of appeals received as compared to 2008. The majority of appeals are received January through April although requests are received in every month including December.

In 2009, the Part D QIC reversed plan decisions in 65% of cases, as follows:
Drug utilization management tool dispute: 71%
Out-of-network pharmacy coverage: 67%
Off-formulary exception request: 60%
Tiering exception request: 41%
Cost-sharing dispute: 21%

Most standard cases were processed in 6 days and most expedited cases were processed in 1 or 2 days.

Click below for:
Medicare Part D Reconsideration Appeals Data 2009   2008   2007   2006

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• Jump to CMS Medicare Part D Appeals Process Flowchart

3. Hearing with an Administrative Law Judge

You will receive a written decision from the IRE. If you disagree with the IRE’s decision, you or your representative can request an Administrative Law Judge (ALJ) hearing. You must make the request in writing within 60 calendar days from the date on the IRE’s decision letter. You must send your request to the location listed in the IRE’s decision letter. To get an ALJ hearing, the dollar value of your denied coverage must be at least a certain amount. For 2011, the dollar value of your denied coverage must be at least $130.(you may be able to combine claims to meet this dollar amount). The IRE’s decision will include the amount.

The ALJ hearing will be conducted by telephone or by video-teleconference. You may also request an in-person hearing. At the ALJ hearing, you will have the chance to explain why your Medicare drug plan should cover your drug or pay you back. You may also ask your doctor or other prescriber to join the hearing and explain why he or she believes the drug should be covered.

• Jump to CMS Medicare Part D Appeals Process Flowchart

4. Review by the Medicare Appeals Council

You will receive a written decision from the ALJ. If you disagree with the ALJ’s decision, you or your representative can request a review by the Medicare Appeals Council (MAC). You must make the request to the MAC in writing within 60 calendar days from the date on the ALJ’s decision letter. Send your request to the location listed in the ALJ’s decision letter.

• Jump to CMS Medicare Part D Appeals Process Flowchart

5. Review by a Federal court

You will receive a written decision from the MAC. If you disagree with the MAC’s decision, you or your representative can request a review by a Federal court. You must make the request in writing within 60 calendar days from the date of the MAC’s decision notice. You should check with the clerk’s office of the Federal court for instructions about how to file the appeal. The court location will be listed in the MAC’s decision notice. To get a review by a Federal court, the dollar value of your denied coverage must be at least a certain amount. For 2011, the dollar value of your denied coverage must be at least $1,300. (You may be able to combine claims to meet this dollar amount). The MAC’s decision will include the amount.