To make your first Appeal, you must submit a written request to your Medicare 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 Medicare 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 their statement that the Decision must be Expedited.
Your Medicare Part D plan will decide if you qualify for an Expedited Redetermination depending on the seriousness of your health condition.
NOTE: Your Medicare 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 Medicare 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 Maine Elders at
1-877-774-7772
NOTE: Your Medicare Part D plan's written Redetermination decision will explain how to request the next level of Appeal, which is called Reconsideration.
