If a plan sponsor issues an unfavorable coverage determination, an enrollee may request a review of the coverage determination through the Part D appeals process.

There are five successive levels of appeal in the Medicare Part D program.

1. Redetermination by the Part D Plan Sponsor
2. Reconsideration by the Independent Review Entity
3. Hearing by an Administrative Law Judge
4. Review by the Medicare Appeals Council
5. Review by a Federal District Court

An enrollee may appeal to the next level of appeal when the lower appeal entity issues a decision that is unfavorable to the enrollee.  Each unfavorable decision will contain the information an enrollee needs to file an appeal request.

Use the navigation tool on the left side of this page to link to subpages that contain detailed information about each of the five levels of appeal.

Downloads
Flow chart: Medicare Part D Appeals Process [pdf, 28kb] Plan Sponsor Grievance, Coverage Determination, and Appeals Contacts [zip, 180kb]
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