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Medicare Part D Prescription Drug Appeal

Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). If you have Medicare Part D and your drug is denied, you can appeal that decision.

When you are at the pharmacy to fill your prescription, the pharmacist will get a coverage determination stating your insurance plan’s decision whether they will pay for your drug and if so, how much. Your Medicare Part D drug insurance plan will usually send this coverage determination to you in writing or the pharmacist can give you a copy.

If you disagree with this decision, you are allowed to appeal. There are five levels of appeal. You start at Level 1 and if you still don’t agree with their decision, you can then try Level 2 and so on. Each level allows different conditions.

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LEVEL 1: Redetermination from your plan

Medicare Part D appeal Level 1 asks your Medicare insurance company to change their decision. You must do this within 60 days from the date of the coverage determination (the day they made their decision).

Each Medicare Part D plan may have slightly different directions on how to ask for a Level 1 appeal. The coverage determination letter should include the appeal directions. Your doctor can help with this process. Usually it starts with a phone call to the insurance company. Sometimes it includes a special form to fill out and send with additional medical information.

There are two types of Level 1 appeals. You can ask for a standard redetermination or a fast redetermination.

  • Standard appeal. Usually done in writing but some Medicare Part D insurance plans let your doctor do this by phone. Once the insurance company has your appeal, it takes up to seven days to decide.
  • Fast. This is done when your doctor tells them (or the insurance company already knows) that waiting more than three days for a decision is too long because of the seriousness of your health condition. Once they have your appeal, it takes up to three days to decide.

Your insurance company must accept any written Level 1 request from you, your representative, your, or other prescriber. The written request needs to include:

  • Your name
  • Your address
  • Your phone number
  • Your Medicare number
  • Reason(s) why you're appealing
  • The name of the drug you want your plan to cover
  • If you have an appointed representative, a copy of the “appointment of representative” form
  • Any other information that may help, including medical records

LEVEL 2: Review by an Independent Review Entity

If you disagree with the Level 1 decision, you can appeal. You have 60 days from the date of that decision to do a Level 2 appeal.

The Level 1 decision letter should come with a request for reconsideration form. You can also check with your Medicare Part D insurance plan on the process.

Just like Level 1, you can do a standard or fast appeal. Once they have your standard Level 2 appeal, it takes up to seven days to decide. It takes up to three days to decide a fast Level 2 appeal.

You will get a Medicare Reconsideration Notice with the answer to your appeal.

LEVEL 3: Hearing before an Administrative Law Judge (ALJ)

If you disagree with the Level 2 decision, you can appeal. You have 60 days from the date of that decision to do a Level 3 appeal. However, the dollar amount of the drug you are appealing must be a certain amount. (For 2013, it is $140 or higher.) You may be able to put two appeals together to meet this amount.

You can request a hearing in two ways:

  1. Use their form. Fill out a Request for Medicare Hearing by an Administrative Law Judge form.
  2. Write your own request: Follow the directions on the Medicare Reconsideration Notice you got after Level 2. You must send your request to the appropriate Office of Medicare Hearings and Appeals (OMHA) Central Operations. You can find the address in the Medicare Reconsideration Notice.

    Written requests need to include:

    • Your name
    • Your address
    • Your phone number
    • Your Medicare number
    • Reason(s) why you're appealing the Level 2 decision
    • The name of the drug you want your plan to cover
    • A copy of your “Medicare Reconsideration Notice,” which includes information about your case, including a possible document control number
    • The dates of the Level 2 decision you are appealing
    • If you have an appointed representative, a copy of the “appointment of representative” form
    • Any other information that may help, including medical records

Most Level 3 appeals are done within three months. If the administrative law judge doesn't do this within three months, you can ask that they move your case right to Level 4.

For more detailed information on Level 3:

LEVEL 4: Review by Medicare/MAC Appeals Council

If you disagree with the Level 3 decision, you can appeal. You have 60 days after you get the Level 3 decision to move to Level 4.

For Level 4, you request that the Medicare Appeals Council (Appeals Council) review the Level 3 decision. Follow the directions in the Level 3 decision paperwork. You must send your request to the Appeals Council’s address in that document.

You can file a Level 4 appeal in one of two ways:

  1. Use their form: Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form
  2. Write your own request: Send a written request to the Appeals Council that includes:
    • Your name
    • Your address
    • Your phone number
    • Your Medicare number
    • Reason(s) why you are appealing the Level 3 decision
    • The name of the drug you want your plan to cover
    • A copy of your “Medicare Reconsideration Notice,” which includes information about your case, including a possible document control number
    • The dates of the Level 3 decision you're appealing
    • If you have an appointed representative, a copy of the “appointment of representative” form
    • Any other information that may help, including medical records
    • If you are appealing at this level because the administrative law judge didn’t do your Level 3 appeal within three months, include the name of the hearing office where your appeal is still pending

Most Level 4 appeals are done within three months. If the Appeals Council doesn't do this within three months, you can ask that they move your case right to Level 5.

For more detailed information on Level 4 you can:

  1. Go to the Medicare Operations Division website.
  2. Call 1-800-MEDICARE (1-800-633-4227)

LEVEL 5: Judicial Review by a Federal District Court

If you disagree with the Appeals Council's Level 4 decision, you can appeal. You have 60 days after you get the Level 4 Appeals Council's decision to move to Level 5.

However, the dollar amount of the drug you are appealing must be a certain amount or higher. (In 2013, it is $1,400 or higher.) You may be able to put two appeals together to meet this amount.

Follow the Level 5 appeal directions from the Appeals Council decision letter you got after Level 4.

Can someone else do a Medicare Part D appeal for me?

Your doctor can help a lot with your appeal. However, Medicare needs your permission in writing for some parts of the process. You can pick a friend, family member, doctor or advocate. The easiest way to give someone permission is to complete an Appointment of Representative form: 

Download Form

Send this completed form along with the appeal.

If you need someone to do the appeal for you but no one is available, you can call the State Health Insurance Assistance Program (SHIP). They may be able to help.

To find your state’s SHIP office phone number, you can either

  1. Find it online at State Health Insurance Assistance Program
    • Click on the dropdown arrow next to Choose Organization
    • Select SHIP
    • Select your state
    • Select Find Contacts
    • Find the phone number to call
  2. Call the number on the back of your Medicare card. Here is the main Medicare website with detailed information for Medicare prescription drug appeals: Visit medicare.gov

For any other questions, call 1-800-MEDICARE (1-800-633-4227)

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