Appeals

What kinds of decisions can be appealed?

If you are not satisfied with our coverage determination decision, you may ask for an appeal called a "redetermination."  You may generally appeal the following decisions:

• We do not cover a Medicare Part D drug you think you are entitled to receive,
• We do not pay you back for a Medicare Part D drug that you paid for,
• We paid you less for a Medicare Part D drug than you think we should have paid you,
• We ask you to pay a higher co-payment amount than you think you are required to pay for a Medicare Part D drug, or
• We deny your exception request. 

How does the appeals process work?

There are five levels in the appeals process.  At each level, your request for Medicare Part D prescription drug benefits or payment is considered and a decision is made.  The decision may give you some or all of what you have asked for, or it may not give you anything you asked for.  If you are unhappy with the decision, you may be able to appeal it and have someone else review your request.

The following chart summarizes the appeals process.  Each appeal level is discussed in greater detail after the chart.

*The adjudication time frames generally begin when the request is received by the Plan sponsor.  However, if the request involves an exception to the Plan’s formulary, the adjudication time frame begins when the Plan sponsor or independent review organization receives the doctor’s supporting statement. 

Appeal Level 1: If we deny any part of your request in our coverage determination, you may ask us to reconsider our decision. This is called a “request for redetermination.”

You may ask us to review our coverage determination, even if only part of our decision is not what you requested.  When we receive your request to review the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination.  This helps ensure that we will give your request a fresh look.

Appeal Level 2: If we deny any part of your first appeal, you may ask for a review by a government-contracted independent review organization.

At the second level of appeal, your appeal is reviewed by an outside, independent review organization that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program.  The independent review organization has no connection to us.  You have the right to ask us for a copy of your case file that we sent to this organization. 

Appeal Level 3: If the organization that reviews your case in Appeal Level 2 does not rule completely in your favor, you may ask for a review by an Administrative Law Judge.

If the independent review organization does not rule completely in your favor, you or your appointed representative may ask for a review by an Administrative Law Judge if the dollar value of the Medicare Part D drug you asked for meets the minimum requirement provided in the independent review organization's decision. During the Administrative Law Judge review, you may present evidence, review the record (by either receiving a copy of the file or accessing the file in person when feasible), and be represented by counsel.

Appeal Level 4: If an ALJ does not rule in your favor, your case may be reviewed by the Medicare Appeals Council

If the Administrative Law Judge does not rule completely in your favor, you or your appointed representative may ask for a review by the Medicare Appeals Council

Appeal Level 5:  If the Medicare Appeals council does not rule in your favor, your case may go to a Federal Court

You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:

• The decision is not completely favorable to you, or
• The decision tells you that the Medicare Appeals Council decided not to review your appeal request.