Medicare drug plan appeals and exceptions

If a Medicare drug plan (Part D) will not cover a medicine, you do not have to accept the first answer. The steps are different from a Medicare Advantage or Original Medicare appeal in two ways: the first request is often an exception that your prescriber must support, and the outside review step is yours to start. The reference page is Medicare drug plan (Part D).

What this means

There are three kinds of request, and the plan’s name for the first decision is a coverage determination.

• A coverage determination. You or your prescriber ask the plan to cover or pay for a drug. A refusal at the pharmacy is not yet a written denial. Ask the plan for its decision in writing.
• A formulary exception. You ask the plan to cover a drug that is not on its formulary, its list of covered drugs. Your prescriber must give an oral or written statement that the drug is medically necessary for one of the listed reasons.
• A tiering exception. You ask the plan to charge a lower cost-sharing tier for a drug. Your prescriber must say that the preferred drug would not be as effective or would have adverse effects for you.

A plan may exclude specialty-tier drugs from tiering exceptions to non-specialty tiers, and need not move a brand-name drug to a tier that contains only generics.

What to do

1. Ask the pharmacy and the plan why (you). Get the reason in writing. Ask whether the drug is off-formulary, needs prior authorization or step therapy, or has a limit.
2. Ask your prescriber for a supporting statement (your prescriber). For an exception, the plan’s clock starts when it receives the statement. If no statement arrives within 14 calendar days, the plan decides within 72 hours (24 hours if fast) after that 14-day period ends. A quick statement saves time.
3. Ask for the coverage determination (you or your prescriber). The plan must answer a request for a drug within 72 hours, or 24 hours if you ask for an expedited decision. Ask your prescriber to say in the request if waiting could seriously harm your health. A request for payment (reimbursement) is due in 14 calendar days. If the plan misses the deadline, that counts as a denial, and the plan must forward your request to the outside reviewer within 24 hours.
4. File the first appeal, called a redetermination (you or your prescriber). The deadline is 65 calendar days from the date on the denial notice. The rule says 60 days after receipt, with receipt presumed 5 days after the notice date. The plan decides in 7 calendar days, or 72 hours if fast, or 14 calendar days for a payment request.
5. Ask for the outside review yourself (you or your prescriber). If the plan upholds the denial, it does not send the case on. You, your representative or your prescriber must file a written request with the Independent Review Entity within 60 days after receipt of the redetermination notice. The Centers for Medicare & Medicaid Services (CMS) counts that as 65 days from the notice date. The entity is C2C Innovative Solutions, Inc. It decides within the same times as the plan.
6. Later levels (you). A judge, the Council and then federal court follow, with the same dollar minimums as other Medicare appeals: $200 and $1,960 for 2026. The judge is to decide within 90 calendar days, or 10 if an expedited hearing is granted.

Check the date on your notice, which controls.

What the plan may say, and what to say back

“The drug is not on our formulary.”

Ask for a formulary exception and send your prescriber’s statement that the drug is medically necessary.

“You must try the cheaper drug first.”

Ask for an exception and have your prescriber explain why the other drug would be less effective or cause harm to you.

The rule

The independent review entity’s reconsideration of a Part D denial is not automatic: you must file a written request within 60 calendar days after receipt of the redetermination notice. (Title 42 of the Code of Federal Regulations (CFR), section 423.600(a))

Watch for

• Out-of-date pages. Older web pages, including some official ones, can lag the regulation on dollar amounts and deadlines. This page uses the regulation and the annual Federal Register notice; if a page or letter shows different figures, use the stricter date and ask the plan which applies.
• New plan, new drug. In the first 90 days of coverage with a new plan, the plan must give a one-time temporary supply of at least a month’s worth of a drug that is off-formulary or needs prior authorization or step therapy. It must send written notice within 3 business days.
• Formulary changes. Before a negative formulary change, the plan must generally give affected members at least 30 days’ written notice, or a refill with notice when you ask. This site has not read the exceptions to that rule.
• How long a win lasts. Medicare Rights Center says a win may last only to the end of the calendar year. Ask the plan in writing how long yours lasts.
• Drugs given in a doctor’s office. Those are Part B drugs, not Part D. With Medicare Advantage, see Medicare Advantage appeals. With Original Medicare, see the five appeal levels.

What next

• Formulary exceptions shows how to write the request with your prescriber.
• Step therapy exceptions covers the “try the other drug first” denial.
• Free Medicare counseling tells you how to reach a State Health Insurance Assistance Program counselor.
• Medicare, Medicare Advantage and drug plans lists every Medicare page.