Guide to Medicare Part D: Appeals

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This page is part of our Guide to Medicare Part D.

See Medicare Part D Appeals [PDF], a guide to navigating the Medicare private drug plan appeals process, produced by the Medicare Rights Center.

To make your first Appeal, you must submit a written request to your Part D plan. The written coverage determination is needed before the appeals process may begin.   

Your first Appeal is called a Redetermination. 

You will have 60 days from the date on the written notice of the Coverage Determination or Exception decision to submit a request for Redetermination.

What do I include in my Appeal?
You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. This may include evidence that your drug is medically necessary. To be successful you will need documentation from your doctor that the drug is medically necessary and that no reasonable alternative therapy will work. Submit all receipts for medications paid for out-of-pocket while the appeal is pending. 

What happens next?

Redeterminations must be decided and implemented within 7 days after your Part D plan receives the request for Redetermination.

What if I can't wait 7 days?

You can request an Expedited Redetermination.

If you or your doctor believes that waiting 7 days might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Part D plan to request an Expedited Redetermination.

Your Part D plan will decide if you qualify for an Expedited Redetermination depending on the seriousness of your health condition.

NOTE: Your Part D plan MUST grant a request for an Expedited Redetermination if your doctor personally calls your Part D plan and states that waiting 7 days for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Part D plan grants the request for an Expedited Redetermination, it must contact you within 72 hours to notify you of its Redetermination decision.

What if the Redetermination decision is unfavorable?

If the Redetermination decision is unfavorable, you have the RIGHT to request the next level of Appeal.

For questions or advice, contact
your nearest Kentucky legal services program.

 

NOTE: Your Part D plan's written Redetermination decision will explain how to request the next level of Appeal, which is called Reconsideration.


Reviewed August 2009

This online guide was adapted with permission from Maine Legal Services for the Elderly. We extend our thanks to them.