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 may include evidence
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 you or your doctor believes that waiting 7 days might seriously jeopardize
your health, life, or ability to regain maximum function, you or your doctor
can call your Part D plan to request an Expedited Redetermination.
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 personally calls your Part D plan and 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
Legal Services for the Elderly at 1-800-750-5353
|
| NOTE: Your Part
D plan's written Redetermination decision will explain how to request
the next level of Appeal, which is called Reconsideration. |
