Medicare Part D appeal checklist

Confirm the correct process

• Verify that the dispute concerns a Medicare Part D prescription drug, exception, utilization-management rule, cost-sharing amount, or payment request.
• Confirm that the plan issued a formal unfavorable coverage determination.
• Do not use this checklist for an Original Medicare Part A or B claim or a Medicare Advantage medical-service denial.

Protect the deadline

• Find the date on the initial denial notice.
• Calendar the current CMS filing period of 65 calendar days from that notice date.
• If filing after the deadline, prepare a concise explanation for the late request.
• Use the exact channel and destination printed in the notice.

Collect identification and case details

• Name and safe contact information.
• Medicare number, shared only through the plan's accepted secure process.
• Plan name and member information.
• Drug name, strength, dosage, prescription date, and pharmacy information when relevant.
• Copy of the coverage determination and any pharmacy notice.
• Representative appointment document when another person is filing.

Build the coverage argument

• Write a short statement explaining the part of the decision you dispute.
• Ask the prescriber for records or a statement explaining why the requested drug or exception is medically necessary.
• Identify drugs tried, adverse effects, contraindications, or other facts relevant to the plan's reason.
• For an exception, confirm that the prescriber supplies the required supporting statement.
• Do not send original records that cannot be replaced.

Decide whether to request an expedited appeal

• Ask whether waiting for the standard 7-day decision may seriously jeopardize life, health, or the ability to regain maximum function.
• Request the expedited redetermination orally or in writing.
• Ask the prescriber to state the urgency directly to the plan when appropriate.
• Remember that reimbursement for a drug already received uses the standard payment process.

Submit and document the request

• Use the plan's telephone, fax, portal, or mailing instructions.
• Record the date and time, representative's name, confirmation number, and documents sent.
• Keep a complete copy and proof of delivery.
• Ask when the plan considers the request received and what decision timeframe applies.

After filing

• Respond promptly to requests for additional information.
• For an accepted expedited appeal, watch for a decision no later than 72 hours after receipt.
• For a standard drug-benefit appeal, watch for a decision no later than 7 calendar days after receipt.
• For a payment appeal, watch for written notice generally within 14 calendar days.
• Read any unfavorable decision immediately for independent-review instructions and the next deadline.

Official sources

• Medicare.gov — Part D appeal steps
• CMS — level 1 redetermination
• CMS — Part D coverage and appeal forms

Related resources

• Step-by-step Part D appeal
• Fast appeal requirements
• Coverage determination definition
• CMS agency profile