Appeals in a Medicare drug plan

Appeals of coverage decisions in a Medicare drug plan are called Coverage Determination Requests. When you’re in a plan, you have the right to a coverage determination, either orally or written, to see if a drug is covered. Contact your plan to get a coverage determination.

• If you're asking to get paid back for a drug you already bought: You or your prescriber must make the standard request in writing. Write your plan a letter, or send them a completed "Model Coverage Determination Request" form. Find the form and instructions at the bottom of the page under "Downloads."
• If you're asking for a drug you haven't gotten yet: You or your prescriber can ask your plan for a coverage determination or an exception. To ask for a coverage determination or exception, you can do one of these:
  • Send a completed "Model Coverage Determination Request" form.
  • Write  your plan a letter.
  • Call your plan.
• If you're asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.

You or your prescriber can ask for an expedited (fast) request. Your request will be expedited if your plan determines, or your prescriber tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.

If you disagree with the coverage decision, you would start the appeal process through your plan.

How do I start an appeal?

Level 1 appeals in a Medicare drug plan are called redeterminations. If you disagree with the initial decision from your plan, you, your representative or prescriber can ask for a redetermination. Follow the directions in the plan's initial denial notice and plan materials to start your appeal.

You, your representative, or your prescriber must ask for an appeal within 60 days of getting the plan’s initial denial notice. If you miss the deadline, you must give a reason for filing late.

Include this information in your appeal:

• Your name, address, and the Medicare Number on your Medicare card.
• The drug you’re appealing and the reason(s) why you're appealing.
• The name of your representative and proof of representation if you’ve appointed a representative. How do I appoint a representative?
• Any other information (like a prescriber supporting statement that may help your appeal).

If you think your health could be seriously harmed by waiting the standard 7 days for a decision, ask your plan for a fast or "expedited" appeal. The plan must give you its decision within 72 hours if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your health.

How long your drug plan has to respond to your appeal depends on the type of appeal you’re filing:

Standard Process:

• Benefits appeal: 7 days
• Payment appeal: 14 days

Fast appeal: 72 hours

If you disagree with the plan’s redetermination decision:

You have 60 days from the date of the decision to request a Reconsideration by a Qualified Independent Contractor.

If your plan upholds their denial in your level 1 appeal and you disagree with the decision, you’ll have 60 days to file a Standard Reconsideration with a Part D Independent Review Entity (IRE) to start a level 2 review. Your plan will send you a denial letter with information on your appeal rights.

How long the IRE has to respond to your appeal depends on the type of appeal you’re filing:

Standard Process:

• Benefit appeal: 7 days
• Payment appeal: 14 days

Fast appeal: 72 hours

If you disagree with the Part D IRE's decision in level 2:

You have 60 days from the date of the Part D IRE's decision to ask for a level 3 appeal, which is a decision by the Office of Medicare Hearings and Appeals (OMHA).

If you file an appeal with OMHA the amount of your case must meet a minimum dollar amount. For 2024, the minimum dollar amount is $180.

You can ask for a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, if you don’t wish to have a hearing, you can ask for an on the record review of your appeal by an ALJ or attorney adjudicator. To ask for a hearing before an ALJ, follow the directions on the "Medicare Reconsideration Notice" you got from the Qualified Independent Contractor (QIC) in your level 2 appeal.

A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a decision. An ALJ hearing is usually held by phone or video-teleconference, but can also be held in person if the ALJ finds that you have a good reason.

You or your representative can ask for a hearing in one of these ways:

• Fill out a "Request for Medicare Hearing by an Administrative Law Judge" form.
• Submit a written request, which must include:
  • Your name, address, phone number, and Medicare Number. If you've appointed a representative, include the name, address, and phone number of your representative.
  • The appeal number assigned by the QIC if any.
  • The dates of service for the items or services you're appealing. 
  • Why you disagree with the QIC's decision.
  • Any information that may help your case. If you can't include this information with your request, include a statement explaining what you plan to submit and when you'll submit it.
• File an appeal online with OMHA.

Get more information about the ALJ hearing process or call us at 1-800-MEDICARE (1-800-633-4227).

How do I ask for a review of my case without a hearing?

You can ask OMHA to make a decision without holding a hearing (based only on the information that's in your appeal record). The ALJ or attorney adjudicator may also issue a decision without holding a hearing if the appeal record supports a decision that's fully in your favor.

To ask OMHA to make a decision without a hearing (based on only the information that's in your appeal record), submit the information required for an ALJ hearing (listed above) and one of these:

• The "Waiver of Right to an Administrative Law Judge (ALJ) Hearing" form (Form OMHA-104).
• A written request stating that you don't want to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference)

Even if you waive the ALJ hearing, a hearing may still be held by an ALJ if the other parties in your case who were sent a notice of hearing (for example, your provider) don’t also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide your case.

If you asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and make a decision.

You can ask to move to appeals level 4 if:

• OMHA doesn't issue a timely decision.
• You disagree with the OMHA's decision.

You have 60 days after you get the decision to move to appeals level 4, by asking for a review by the Medicare Appeals Council (Appeals Council).

To ask for a level 4 appeal, follow the directions in the ALJ's hearing decision you got in the level 3 appeal.

You can ask for the Medicare Appeals Council (Appeals Council) review in 1 of 2 ways:

• Fill out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" form [PDF, 30.5 KB].
• Submit a written request to the Appeals Council that includes:
  • Your name and Medicare Number. If you've appointed a representative, include the name of your representative. How do I appoint a representative?
  • The specific item(s) and/or service(s) and specific date(s) of service you're appealing.
  • A statement describing what you disagree with in the ALJ's decision and why.
  • The date of the ALJ decision.
  • If you're asking that your case be moved from the ALJ to the Appeals Council because the ALJ hasn't issued a timely decision, send your ask to the OMHA address listed on the QIC's reconsideration notice (or if you know that your case was assigned to an OMHA adjudicator, to the hearing office where it’s pending).

For more information about the Appeals Council review process, visit HHS.gov, or call us at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

You can request judicial review in Federal district court (level 5) if:

• The Appeals Council doesn't issue a timely decision.
• You disagree with the Appeals Council's decision in level 4.
• The amount of your case meets a minimum dollar amount. For 2024, the minimum dollar amount is $1,840. You may be able to combine claims to meet this dollar amount.

You have 60 days after you get the Appeals Council’s decision to ask for judicial review by a federal district court.

To get a judicial review in Federal district court, the amount of your case must meet a minimum dollar amount. For 2024, the minimum dollar amount is $1,840. You may be able to combine claims to meet this dollar amount.

Follow the directions in the Appeals Council’s decision letter you got in your level 4 appeal to file for judicial review in federal court.