To make your first Appeal, you must submit a written request
to your Part D plan.
Your first Appeal is called a Redetermination.
You will have 60 days from the date on the written notice of the Coverage
Determination or Exception decision to submit a request for Redetermination.
What do I include in my Appeal?
You should include your name, address, Member ID number, the reasons for
appealing, and any evidence you wish to attach. This must include
a statement from your doctor that that your drug is medically
necessary. |
What happens next?
Redeterminations must be decided and implemented within 7 days after your
Part D plan receives the request for Redetermination.
What if I can't wait 7 days?
You can request an Expedited Redetermination.
If your doctor believes that waiting 7 days might seriously jeopardize
your health, life, or ability to regain maximum function, your doctor should
include in his/her statement that the Decision must be Expedited.
Your Part D plan will decide if you qualify for an Expedited Redetermination
depending on the seriousness of your health condition.
| NOTE: Your
Part D plan MUST grant a request for an Expedited Redetermination
if your doctor states that waiting 7 days for a decision might seriously
jeopardize your health, life, or ability to regain maximum function. |
If your Part D plan grants the request for an Expedited Redetermination,
it must contact you within 72 hours to notify you of its Redetermination
decision.
What if the Redetermination decision is unfavorable?
|
If the Redetermination decision is unfavorable,
you have the RIGHT to request the next level of Appeal.
For questions or advice, contact the Medicare Part
D Appeals Unit of Legal Services for the Elderly at 1-877-774-7772.
|
| NOTE: Your Part
D plan's written Redetermination decision will explain how to request
the next level of Appeal, which is called Reconsideration. |
