Where do I go to appeal a decision by my plan not to cover a needed drug?

When you are unable to get needed medication, you should contact your plan and request an exception and a coverage determination. The plan then has 72 hours to respond to your request (24 hours for an expedited appeal). Plans are expected to provide temporary supplies of non-covered drugs to affected beneficiaries when a plan is unable to meet the imposed time frames for coverage determinations, redeterminations or in forwarding cases to the Independent Review Entity. If you disagree with the outcome of a coverage determination, there are several levels of appeals that can help you obtain your medication.

Redetermination by Plan The first step in the appeals process is to ask the plan to reconsider its coverage determination. You, your appointed representative or your doctor can appeal your plan’s decision by phone or letter. Your appeal must be requested within 60 calendar days of the plan’s coverage determination. The plan then has seven days to respond to your request (72 hours for an expedited appeal). Plans are expected to provide temporary supplies of non-covered drugs to affected beneficiaries when a plan is unable to meet appeal time frames.

Independent Review Entity (IRE) If your plan again denies coverage, you can appeal to the Independent Review Entity (IRE). The IRE is an independent agency that contracts with Medicare to handle these appeals and is not connected to any private drug plan. An appeal to the IRE must be made within 60 days from the date of the redetermination. The IRE has seven days to respond to your request (72 hours for an expedited appeal). You can find more information on appeals to the IRE and relevant forms at www.medicarepartdappeals.com/.

Administrative Law Judge (ALJ) If you are dissatisfied with the reconsideration by the IRE, you can request a hearing with an Administrative Law Judge (ALJ) from the Department of Health and Human Services. The ALJ hearing request must be made within 60 days of the IRE decision. You can only receive an ALJ hearing if the value of denied coverage exceeds a minimum amount ($170 in 2020). The ALJ is supposed to make a decision within 90 days, but extensions of the time limit can be granted. ALJ hearings are generally conducted over the phone or through video teleconference.

Medicare Appeals Council (MAC) If you disagree with the ALJ decision, you can request a review by the Medicare Appeals Council (MAC), which is part of the Department of Health and Human Services. Your request to the MAC must be made within 60 days of the ALJ decision. The MAC will generally decide on your appeal within 90 days.

Judicial Review If all else fails, and the amount in question exceeds a minimum amount ($1,670 in 2020), you may request judicial review in federal district court. Your request for judicial review must be made within 60 days of the MAC decision.