If you disagree with a Medicare payment or coverage decision for a service, item, test or prescription, you can appeal. Different parts of Medicare have different steps for appeal.
Appeals for Medicare Parts A & B — often called “Original Medicare”
To start the appeal process, you will need a notice from Medicare called a Medicare Summary Notice. You get these every three months. They explain what Medicare has covered and what you may owe from that three-month period. You must make your appeal within 120 days of getting the Medicare Summary Notice.
There are five levels of appeal. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll get instructions in the decision letter on how to move to the next level of appeal.
Appeals for Medicare Part D prescription drug plans
If your Part D plan says that it won’t cover a prescription that you need, you can appeal that decision.
Step 1: The first step in an appeal is to ask for a “coverage determination” from your plan. This is the written explanation of what the Part D plan will cover. The standard time frame to get this information is 72 hours. You can ask to get it within 24 hours if you have an emergency need such as needing essential medication.
Step 2: The second step in the Part D appeal process is to ask for a “Standard Redetermination.” The standard time frame is seven days for benefits. You can ask for it to be “expedited” (faster) and get it in 72 hours.
There are more appeal levels in the Part D process. See this flow chart for an overview of the entire appeal process.
Visit the links below for more information on getting your prescriptions covered by your Part D plan.
- Learn more about exceptions on the CMS website.
- Learn about coverage determination and exceptions on the Medicare Interactive website.
Switching Part D plans
You may also want to see if you have special enrollment period that allows you to switch to a Part D plan that covers the medication.
If you have Extra Help or Medicaid, you are entitled to one special enrollment period once per calendar quarter during the first nine months of the year.
If you have VPharm, you are entitled to one special enrollment period per year to switch Part D plans.
Have more questions?
Contact us at the Office of the Health Care Advocate (HCA) by filling out this form or calling 1-800-917-7787. There is no charge for our help. If you have a time-sensitive, urgent need, please call us instead of using our form.