Appeal a Medicare Part D drug coverage decision

Use the drug plan's appeal process

This procedure is for a Medicare Part D drug coverage decision, including drug coverage offered through a standalone Part D plan or the drug portion of a Medicare Advantage plan. Original Medicare Part A or Part B claims and Medicare Advantage medical-service decisions use different appeal routes.

1. Confirm that the plan made a coverage determination

A Part D coverage determination is the plan's formal decision about a requested prescription drug, payment for a drug, an exception, the amount you must pay, a quantity limit, step therapy, prior authorization, or another drug-coverage requirement. If the pharmacy only gave you a rejection message, contact the plan and ask whether a formal coverage determination has been issued.

2. Read the denial notice immediately

The written notice identifies the drug, explains why the request was denied in whole or in part, gives the plan's appeal address or other accepted channel, and states the filing deadline. CMS currently instructs an enrollee, representative, or prescriber to request the level 1 redetermination within 65 calendar days from the date on the initial denial notice. If the request is late, explain the reason for filing after the deadline.

3. Choose standard or expedited review

A standard redetermination for a drug benefit generally must be requested in writing unless the plan accepts oral requests. An expedited request may be made orally or in writing. Ask for expedited review when waiting for the standard decision may seriously jeopardize your life, health, or ability to regain maximum function. A prescriber's support is especially important; when the prescriber states that the standard timeframe creates that risk, the plan must expedite the appeal under the federal rule.

An expedited appeal is not available for a request to be reimbursed for a drug you already received.

4. Include the information the plan needs

Your name, address, and Medicare number.
The name, strength, and dosage of the drug being appealed.
The date and reason shown on the denial notice.
A clear explanation of why you disagree with the plan.
Medical records, prior treatment information, or a prescriber statement that supports coverage.
Proof of representation when another person is acting as your appointed representative.
A request for expedited handling and the health reason, when applicable.

For a formulary or utilization-management exception, the prescriber generally must provide a supporting statement explaining the medical reason the exception should be approved.

5. Send the appeal to the plan and keep proof

Use the telephone number, fax, portal, or mailing address in the denial notice or Evidence of Coverage. Do not send the request to CMS headquarters. Keep the notice, complete request, attachments, confirmation number, fax report, portal receipt, or mailing proof. Avoid sending a Medicare number or detailed medical records through ordinary email unless the plan specifically provides a secure method.

6. Track the plan's decision timeframe

Standard drug-benefit appeal: no later than 7 calendar days after the plan receives the request, and sooner when the health condition requires.
Expedited drug-benefit appeal: no later than 72 hours after receipt when expedited handling is approved.
Payment appeal: written notice generally within 14 calendar days after receipt.

These are federal processing limits, not a guarantee that the plan will approve the drug. If the plan does not meet a required timeframe, federal rules require escalation to the independent review level.

7. Review the decision and next-level instructions

If the plan reverses the denial, confirm when it will authorize or provide the drug or issue payment. If the redetermination remains unfavorable, the notice explains how to request reconsideration by the Part D Independent Review Entity. Follow the deadline and destination printed on that new notice; do not reuse the level 1 address.