Medicare Part D Prescription Drug Coverage Appeal

Instructions for Use

This template is for appealing a denial of prescription drug coverage under Medicare Part D (including Medicare Advantage Prescription Drug plans - MA-PD). Part D appeals follow a 5-level process similar to Original Medicare but with different entities and shorter timelines.

Part D Appeals Process (5 Levels):
1. Redetermination by Plan - 60 days to file
2. Reconsideration by Independent Review Entity (IRE) - 60 days to file
3. ALJ Hearing - 60 days to file; $180 minimum (2024)
4. Medicare Appeals Council - 60 days to file; $1,840 minimum (2024)
5. Federal District Court - 60 days to file; $1,840 minimum (2024)

Important 2024-2025 Update: Filing deadline extended from 60 to 65 calendar days as of November 2024.

Part D Coverage Appeal Request

[Date]

VIA FAX AND MAIL (for expedited processing)

[Medicare Part D Plan Name]
[Appeals and Grievances Department]
[Street Address]
[City, State, ZIP]
Fax: ______________________________________________

REQUEST FOR REDETERMINATION - PART D COVERAGE APPEAL
☐ EXPEDITED (FAST) APPEAL REQUESTED

Re: Part D Coverage Determination Appeal

Dear Appeals Department:

I am requesting a redetermination (Level 1 appeal) of the coverage determination dated [DATE] that denied coverage for [MEDICATION NAME]. This appeal is filed pursuant to 42 CFR 423.580 within the required timeframe.

Section 1: Member Information

Plan Information:

Section 2: Prescribing Physician Information

Section 3: Medication Information

Medication Denied

Pharmacy Information

Section 4: Coverage Determination Details

Original Request Information

Type of Denial (check all that apply)

Formulary Issues:
☐ Drug not on formulary
☐ Non-preferred tier (requesting tier exception)
☐ Brand when generic available
☐ Specialty tier drug

Utilization Management:
☐ Prior authorization denied
☐ Step therapy required
☐ Quantity limits exceeded
☐ Age/gender restrictions

Coverage Determination:
☐ Not medically necessary
☐ Off-label use not supported
☐ Experimental/investigational
☐ Part B vs. Part D coverage issue

Other:
☐ Cost-sharing concern (requesting cost exception)
☐ Pharmacy/network issue
☐ Other: ______________________________________________

Denial Reason (from denial notice)

Denial Code: ______________________________________________

Exact Language from Denial:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Section 5: Type of Exception Requested

Check all that apply:

☐ Formulary Exception - Requesting coverage of non-formulary drug
- Requested formulary alternatives tried and failed (list below)
- Would be ineffective for my condition
- Would cause adverse effects

☐ Tiering Exception - Requesting lower cost-sharing tier
- Formulary alternatives at lower tier tried and failed
- Formulary alternatives would be ineffective
- Formulary alternatives would cause adverse effects

☐ Quantity Limit Exception - Requesting more than quantity limit
- Medical necessity for higher quantity
- Standard quantity inadequate for condition

☐ Step Therapy Exception - Requesting to skip required steps
- Already tried required step(s) and failed
- Required step(s) would be ineffective
- Required step(s) contraindicated
- Currently stable on requested drug

☐ Prior Authorization Review - Challenging PA denial decision

Section 6: Urgency - Standard vs. Expedited Appeal

Standard Appeal

• Decision within 7 calendar days
• Used when delay would not cause harm

Expedited (Fast) Appeal

• Decision within 72 hours
• Available when standard timing could seriously jeopardize life, health, or ability to regain maximum function

☐ I REQUEST A STANDARD APPEAL

☐ I REQUEST AN EXPEDITED (FAST) APPEAL

Reason expedited review is needed:

☐ Waiting for standard review could seriously jeopardize my life
☐ Waiting could seriously jeopardize my health
☐ Waiting could jeopardize my ability to regain maximum function
☐ I am experiencing severe symptoms that require immediate treatment
☐ My prescriber certifies urgency (see below)

Physician Certification of Urgency (for expedited appeals)

"I certify that applying the standard review timeframe could seriously jeopardize the life or health of this patient, or the patient's ability to regain maximum function."

Prescriber Signature: ______________________________________________

Date: ______________________________________________

Prescriber Phone (for plan contact): ______________________________________________

Section 7: Medical Necessity Statement

Diagnosis and Condition

Primary Diagnosis (requiring medication):

Secondary/Related Diagnoses:

Why This Medication is Medically Necessary

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Medications Previously Tried (Step Therapy/Alternatives)

Contraindications to Formulary Alternatives

☐ Allergies to formulary alternatives: ______________________________________________
☐ Drug interactions: ______________________________________________
☐ Medical conditions preventing use: ______________________________________________
☐ Previous adverse reactions: ______________________________________________

Expected Benefit of Requested Medication

_______________________________________________________________________________

_______________________________________________________________________________

Consequences if Medication Not Covered

_______________________________________________________________________________

_______________________________________________________________________________

Section 8: Supporting Documentation

Documents Submitted

Medical Records:
☐ Office visit notes documenting condition
☐ Lab results
☐ Treatment history
☐ Specialist consultation
☐ Hospital records (if relevant)

Prescriber Documentation:
☐ Letter of medical necessity
☐ Statement of failed alternatives
☐ Clinical rationale for requested medication
☐ Peer-reviewed literature supporting use

Denial Documentation:
☐ Coverage determination denial notice
☐ Explanation of Benefits
☐ Prior authorization denial (if applicable)

Prescription:
☐ Current prescription

Other:
☐ FDA approval documentation (if off-label)
☐ Compendia support (for off-label use)
☐ Clinical guidelines
☐ Other: ______________________________________________

Section 9: Prescriber's Supporting Statement

Prescriber Statement of Medical Necessity

I am prescribing [MEDICATION NAME] for [PATIENT NAME] because:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

This medication is medically necessary and appropriate for this patient's condition because:

_______________________________________________________________________________

_______________________________________________________________________________

The formulary alternatives are not appropriate for this patient because:

_______________________________________________________________________________

_______________________________________________________________________________

Prescriber Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

NPI: ______________________________________________

Section 10: Authorized Representative (If Applicable)

☐ Patient is filing on own behalf (skip to Section 11)

☐ Representative is filing on patient's behalf

Representative Information

Type of Representative:
☐ Prescriber/physician
☐ Family member
☐ Legal representative
☐ Other: ______________________________________________

☐ CMS-1696 (Appointment of Representative) attached

Section 11: Member Certification

I certify that the information in this appeal is true and correct. I understand:
- The plan will review my appeal and issue a decision
- If my standard appeal is denied, I have the right to request an expedited (fast) appeal or proceed to Level 2 (IRE reconsideration)
- I can submit additional information to support my appeal
- I will receive written notice of the decision

Member Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

Tracking Information

Part D Appeals Process Overview

Level 1: Plan Redetermination (Current Step)

• Who Decides: Your Part D plan
• Timeline: 7 days (standard) / 72 hours (expedited)
• Filing Deadline: 60-65 days from denial

Level 2: IRE Reconsideration

• Who Decides: Independent Review Entity (IRE)
• Timeline: 7 days (standard) / 72 hours (expedited)
• Filing Deadline: 60 days from Level 1 decision
• IRE Contact: Maximus Federal Services

Level 3: ALJ Hearing (OMHA)

• Who Decides: Administrative Law Judge
• Timeline: 90 days
• Filing Deadline: 60 days from Level 2 decision
• Minimum Amount: $180 (2024)

Level 4: Medicare Appeals Council

• Who Decides: Departmental Appeals Board
• Timeline: 90 days
• Filing Deadline: 60 days from Level 3 decision
• Minimum Amount: $1,840 (2024)

Level 5: Federal District Court

• Who Decides: Federal Judge
• Filing Deadline: 60 days from Level 4 decision
• Minimum Amount: $1,840 (2024)

Continuation of Benefits

Important: If you are currently receiving a drug that is being reduced, terminated, or changed, you may be able to continue receiving it during your appeal if you:
- File your appeal before the effective date of the change
- Request continuation of benefits

☐ I request continuation of my current medication while this appeal is pending

Contact Information

Part D Plan Contact

Independent Review Entity (Level 2)

Maximus Federal Services
Phone: 1-800-275-8203
TTY: 1-877-452-2564

Medicare

1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
www.medicare.gov

Resources

• Medicare Part D Appeals: https://www.medicare.gov/claims-appeals/
• CMS Part D Guidance: https://www.cms.gov/medicare/appeals-grievances/prescription-drug
• Part D Manual Chapter 18: https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/
• Medicare Rights Center: https://www.medicarerights.org/

This template is provided for informational purposes only and does not constitute legal advice. Consult with a Medicare specialist or healthcare attorney for specific legal guidance.