You may file an appeal if you are in a Medicare Prescription Drug Plan and you have received a coverage determination from your drug plan sponsor with which you do not agree.
How to Request an Appeal (i.e., "request for redetermination")
- At Level 1, your appeal is called a request for redetermination by your prescription drug plan.
- You must file your appeal in writing within 60 days, unless your drug plan accepts requests by telephone.
- Contact your Medicare Prescription Drug Plan or check your plan materials about the appropriate process for submitting a request for redetermination.
When You Will Get a Response
- Once your drug plan sponsor has received your request, it has seven (7) days (standard request) to notify you of its decision.
- If your prescription drug plan sponsor is unable to complete its decision within the required time frame, it is required to forward your appeal to Level 2.
Special Circumstances for Expedited Review
Your request for redetermination may be expedited if your drug plan determines or your doctor tells your plan that your health will be seriously jeopardized by waiting for a standard decision. For an expedited redetermination, the plan has 72 hours to notify you of its decision.
Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.
