Levels of Appeal in a Drug Plan


If your Medicare prescription drug plan won’t provide you with necessary drug coverage or if you feel you were overcharged, you do have the right to appeal. 

Before appealing, the first step in the process is to request a coverage determination, which is a written explanation about your coverage, from your drug plan. In most cases, you must make this request in writing (although some plans do accept phone requests).  Typically, you will find out the decision of the determination within 72 hours of making the request.

If you disagree with the coverage determination, you have the option of appealing the decision.  This “redetermination” is the first level of appeal and must be filed within 60 days from the date of your coverage determination.  (Your plan will give you information on how to appeal).  If your health is in imminent danger, you can file an expedited request; otherwise, you will file a standard request. Standard requests will receive a reply within 7 calendar days while requests that are expedited will receive a reply within 72 hours. 

If you disagree with the redetermination, you can request a review by an Independent Review Entity within 60 calendar days.  This review is called  a “reconsideration,” and must be requested in writing. The IRE should come to a decision within 7 days for a standard review request.  If your request has been expedited, which happens when the IRE or your doctor concludes your life or health is placed in danger by waiting, you will receive a decision within 72 hours.

If the decision of the IRE is not in your favor, you may request a hearing with an Administrative Law Judge.  This written request must be sent, within 60 calender days from when you receive the reconsideration decision, to the location identified in the notice.  In order to receive a hearing with an Administrative Law Judge, the total value of your denied coverage claim(s) must meet a minimum amount. 

If you object to the decision by the ALJ, your next step is requesting a review by the Medicare Appeals Council.  This request must be made in writing 60 days from the date of the ALJ’s notice, to the location specified therein.

If you object to the decision of the Medicare Appeals council, you can request a review by a Federal court.  Again, this review must be made in writing, 60 calendar days or less from the date of the Medicare Appeals council’s decision notice.  As before, the total value of your claim(s) must meet a minimum dollar requirement. 

The levels of appeal are provided to ensure you have a fair chance to have your case heard.  If you disagree with a decision made by your drug plan, you do, consequently, have options.


Submit Your Comments or Questions Here