Under the Medicare program, you may purchase coverage for prescription medications in one of two ways: through a Medicare Advantage Prescription Drug plan, or through a stand-alone Medicare Part D Prescription Drug Plan to go alongside your Original Medicare (Part A and Part B) benefits.

If you are enrolled in one of these two programs and your plan denies coverage for a prescription medication prescribed by your doctor, you have the right to appeal that decision. Below is an explanation of the process and the steps you need to take.

How do I start the appeals process?

If your doctor does not find that there is another drug on your plan’s formulary that would work for you, you should begin the appeals process by contacting your plan. This information should be found either on your plan ID card or in the materials you received when you enrolled in the plan.

  • Ask for a written explanation (coverage determination), which will explain whether the plan will cover the prescription drug, if there are any requirements you must comply with before the plan will cover it, and if there are exceptions to the coverage rule.
  • Request an exception. If your pharmacist is unable to fill your prescription, he or she should show you the notice so you know why your plan denied coverage.
  • You or your health-care provider can make your request by telephone or by completing and submitting a Request for Medicare Prescription Drug Coverage Determination to your plan administrator at the address provided on your plan materials.

Your plan has 72 hours to respond to your request for an exception, unless your doctor requests an expedited decision, in which case your plan must reply in 24 hours.

How do I ask for a redetermination? (1st level of appeal)

If you are unhappy with your plan’s decision, you have 60 days to initiate the first of five levels of appeal, which is to request a redetermination by your plan. Follow the directions contained in your original decision letter to request the redetermination; you, your doctor, or personal representative can complete this portion of the process. Your plan must reply within 72 hours for an expedited request, or within seven days for standard requests.

What if my plan still denies coverage? (2nd level of appeal)

You have 60 days to move to Level 2, requesting evaluation by an Independent Review Entity (IRE). If your plan decides against you, it will include information for requesting an IRE decision with your determination letter. You or your doctor can request this review and the IRE has up to 72 hours for an expedited request and seven days for a standard request to issue a decision. If the IRE decides against you, you have 60 days to request a hearing before an administrative law judge to review your case.

How do I get a hearing with an administrative law judge (ALJ)? (3rd level of appeal)

An ALJ hearing is a Level 3 appeal and it allows you to present your case before a judge who will make an independent decision. Your claim must involve a certain dollar amount ($160 in 2017) to qualify for an ALJ; the ALJ will decide if the claim meets this threshold. The hearing usually takes place by phone or video conference, although they are occasionally held in person.

You can get more information about the ALJ hearing process; use this form to request review by an ALJ. Mail your request to the following address:

OMHA Central Operations

200 Public Square, Suite 1260

Cleveland, OH 44114-2316

Can I appeal the decision by the ALJ? (4th level of appeal)

If the judge decides against you, information for requesting a Level 4 appeal, or review by the Medicare Appeals Council, will be included in your decision. Complete this form and return it to the address listed on your decision letter. You may also write a letter to the Medicare Appeals Council, following the instructions listed on the Medicare Appeals website. If you are not satisfied with the decision in level 4, you have 60 days to escalate to Level 5 of the Medicare appeals process.

Can I get a judicial review by a federal district court? (Level 5 appeal)

If the amount of your claim meets the financial threshold ($1,560 in 2017), and you have exhausted all other options, you may request judicial review by a federal district court. Follow the instructions provided to you in your determination letter from the Medicare Appeals Council. If you would like a lawyer or advocate to represent you in court, you may appoint a personal representative using this form.

If you have questions about prescription drug coverage and Medicare, I’m happy to assist you. To get started, simply click the Get Quotes button to schedule a phone call or to request a personalized email.