Medicare Part D Prescription Drug Appeal

Many stroke survivors need multiple prescription drugs to ease recovery. Navigating insurance reimbursement can be intimidating. Here’s how the prescription drug plan known as Medicare Part D works. Medicare Part D is private prescription drug insurance offered to Medicare beneficiaries. There are many different plans. Each has its own list of covered drugs, called a formulary. When you fill a prescription, your pharmacist will get a coverage determination stating whether your insurance plan will pay for your drug and if so, how much. Your plan usually sends this determination to you in writing, or the pharmacist can give you a copy. If you disagree with this decision, you can appeal.

There are five levels of appeal.

Level 1:

Redetermination from your plan Level 1 is asking your Medicare insurance company to change their decision. You must act within 60 days from the date the company made its decision. Each plan has slightly different procedures. The coverage determination letter should explain yours. Your doctor can help with this process, which usually starts with a phone call to the insurance company. Sometimes it includes a form to fill out.

There are two types of Level 1 appeals:

  • Standard appeal. This is usually done in writing, but some plans let your doctor do this by phone. After receiving your appeal, the insurance company may take up to seven days to decide.
  • Fast. This is done when your doctor tells the insurance company that waiting more than three days for a decision would take too long because of the seriousness of your health condition. The company may take up to three days to decide.

Your insurance company must accept any written Level 1 request, which should include:

  • Your name, address and phone number
  • Your Medicare number
  • The reason(s) you’re appealing
  • The name of the drug you want your plan to cover
  • A copy of the Appointment of Representative form, if you have an appointed representative (see below) Any other information that might 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 the decision to start 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. You’ll get a Medicare Reconsideration Notice with the answer to your appeal.

Level 3: Hearing before an Administrative Law Judge

If you disagree with the Level 2 decision, you can appeal. You have 60 days from the date of the decision to do a Level 3 appeal. The cost of your care must exceed a minimum amount, which changes yearly. For 2019, it was $160. You can request a hearing in two ways:

Written requests need to include:

  • Your name, address and phone number
  • Your Medicare number
  • The reason(s) 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 A document control number, if your case was given one
  • The dates of the Level 2 decision you’re appealing If you have an appointed representative, a copy of the Appointment of Representative form (see below) Any other information that may help, including medical records

Send your request to the Office of Medicare Hearings and Appeals. You can find the address in the reconsideration notice. Most Level 3 appeals are done within three months. If the administrative law judge doesn’t rule within 180 days, you can ask that the case be moved right to Level 4. For more information on Level 3:

Level 4: Review by Medicare/Medicare Appeals Council

If you disagree with the Level 3 decision, you can appeal. You have 60 days after you get the Level 3 decision. For Level 4, you request that the Medicare 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:

Send a written request to the appeals council that includes:

  • Your name, address and phone number
  • Your Medicare number
  • The 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 Include a document control number, if your case was given one.
  • The dates of the Level 3 decision you’re appealing

A copy of the Appointment of Representative form, if you have an appointed representative (see below) Any other information that might help, including medical records If you’re appealing at this level because the administrative law judge didn’t complete your Level 3 appeal within three months, include the name of the office where your appeal is pending Most Level 4 appeals are done within three months. If the Appeals Council doesn’t rule within three months, you can ask that they move your case right to Level 5.

For more detailed information on Level 4 you can:

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 minimum, which is adjusted yearly. For 2019, the amount is $1,630. 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 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:

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 SHIP Locator button to find your state’s information.

2. Use the information on the back of your Medicare card. The main Medicare website, with detailed information for Medicare prescription drug appeals, is medicare.gov(link opens in new window) You can also call 1-800-MEDICARE (1-800-633-4227).