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Appealing a Medicare Prescription Drug Decision

Adapted from Medicare Appeals, Centers for Medicare & Medicaid Services. The selected guidance concerns Medicare coverage and payment, not a recommendation for medical treatment. Numbered page references below refer to the linked source publication.

Coverage can depend on medical necessity, the setting, provider participation, and your plan’s rules. Use the cited publication for the full conditions and check the plan year when comparing costs or enrollment choices.

File an appeal with Medicare drug coverage

If you have Medicare drug coverage through a Medicare drug plan, a Medicare Advantage Plan with drug coverage (also known as MA-PDs), or other Medicare plan, your plan will send you information that explains your rights (called an “Evidence of Coverage”). Call your plan if you have questions about your “Evidence of Coverage.”

You have the right to ask your plan to provide or pay for a drug you think it should cover, provide, or continue. You have the right to ask for an appeal if you disagree with your plan’s decision about whether to provide or pay for a drug.

If your plan has limited your access to certain medications under its drug management program, you can appeal the plan’s decision. If you appeal, your plan will review your case and give you a decision.

If you decide to appeal, ask your doctor or other health care provider for any information that may help your case. Keep a copy of everything you send to your plan as part of your appeal.

What if my plan won’t cover a drug I think I need?

If your pharmacist tells you that your Part D plan won’t cover a drug you think it should cover, or it will cover the drug at a higher cost than you think you should have to pay, they will give you a notice that explains how to ask for a coverage determination. You have these options:

  • Talk to your prescriber. Ask your prescriber if you meet prior authorization or step therapy requirements. For more information on these requirements, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. You can also ask your prescriber if there are generic, over-the-counter, or less expensive brand-name drugs that could work just as well as the ones you’re taking now.
  • Ask for a coverage determination (including “exceptions”). You, your representative, your doctor, or other prescriber can ask (orally or in writing) your plan to cover the prescription you need. You can ask for a coverage determination if your pharmacist or plan tells you one of these:
  • A drug you believe should be covered isn’t covered
  • A drug is covered at a higher cost than you think you should have to pay
  • You have to meet a plan coverage rule (like prior authorization) before you can get the drug
  • It won’t cover a drug on your plan’s drug list (also called the formulary)

You, or your representative can ask for an “exception” if:

  • You think your plan should cover a drug that’s not on its formulary because the other treatment options on your plan’s formulary won’t work for you
  • Your doctor or other prescriber believes you can’t meet one of your plan’s coverage rules, like prior authorization, step therapy, or quantity or dosage limits
  • You think your plan should charge a lower amount for a drug you’re taking on the plan’s non-preferred drug tier because the other treatment options in your plan’s preferred drug tier won’t work for you

If you ask for an exception, your doctor or other health care provider who prescribed the medicine will need to give a supporting statement to your plan explaining why you need the drug. Check with your plan to find out if the supporting statement must be made in writing. The plan’s decision-making time period begins once your plan gets the supporting statement.

You can either ask for a coverage determination before you pay for your prescriptions, or you can decide to pay for the prescription, save your receipt, and then ask for the plan to pay you back by asking for a coverage determination. Check the “Evidence of Coverage” you get from your plan for more information on getting reimbursed for out-of-pocket costs.

You can ask for a standard coverage determination, or you can file an expedited (fast) request if you haven’t already paid for the drug yourself.

How do I ask for a standard coverage determination?

You, your representative, your doctor, or other prescriber can ask for a coverage determination (including an exception) by filing a request with your plan. A request should be made in writing using the ‘Model Coverage Determination Request’ form. Some plans may allow you to make a request orally. Once your plan gets your standard coverage determination request, they must give you a decision within 72 hours of receipt of your request. For an exception request, they must give you a decision within 72 hours of receipt of the doctor’s supporting statement. They will give you a decision within 14 calendar days for a decision about payment.

How do I ask for an expedited (fast) coverage determination?

You, your representative, your doctor, or other prescriber can call or write your plan to ask that a fast decision be made within 24 hours of your request. If you’re asking for an exception, your plan will give you an answer within 24 hours of getting your doctor’s supporting statement. You’ll get a fast decision if your plan determines, or your doctor or other prescriber tells your plan, that waiting 72 hours for a decision may seriously jeopardize your life, health, or ability to regain maximum function. You can’t request (and won’t get) a fast decision if you’ve already paid for and gotten the drug.

You can call your plan or write them a letter. You can ask them to send you a “Model Coverage Determination Request” form to ask your plan for a fast coverage determination or exception.

What if I disagree with the decision?

Your Part D plan will send you a written decision. If you disagree with this decision, you have the right to file an appeal.

What’s the appeals process for Medicare drug coverage?

The appeals process has 5 Levels: Level 1: Redetermination from your plan Level 2: Reconsideration by an Independent Review Entity (IRE) Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA) Level 4: Review by the Medicare Appeals Council (Appeals Council) Level 5: Judicial Review by a Federal District Court

If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll get instructions on how to move to the next level of appeal.

Level 1: Redetermination from your plan

If you disagree with your plan’s initial denial (coverage determination), you can ask for a redetermination.

You must ask for the redetermination within 65 days from the date of the coverage determination notice. If you miss the deadline, you must give a reason for filing later.

How do I ask for a redetermination?

Follow the directions in the plan’s initial denial notice and plan materials. You, your representative, your doctor, or other prescriber can ask for a standard or fast redetermination. Standard requests must be made in writing, unless your plan allows you to file a standard request orally, like by phone. You’ll get a fast decision if your plan determines, or your doctor or other prescriber tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function. You can’t ask for a fast redetermination if it’s an appeal about payment for a drug you already got.

Your plan must accept any written request for a redetermination from you, your representative, your doctor, or other prescriber. A written appeal should include:

  • Your name, address, and Medicare Number or member number.
  • The name of the drug you want your plan to cover.
  • Reason(s) why you’re appealing.
  • If you’ve appointed a representative, include their name and proof of representation. For more information on appointing a representative, go to page 3.

Send your appeal with any other information that may help your case, including medical records. Your plan’s address and phone number are in your plan materials and will also be in any written plan decision you get.

Your plan will respond in a “Redetermination Notice” within these timeframes:

  • Expedited (fast) redetermination decision: as quickly as your health condition requires, but no later than 72 hours
  • Standard redetermination benefit decision: 7 days
  • Standard redetermination payment decision: 14 days

If you disagree with the plan’s Level 1 redetermination decision, you can ask for a reconsideration by an Independent Review Entity (IRE), which is Level 2. You must ask for the reconsideration within 65 days from the date of your redetermination notice. If you miss the deadline, you must provide a reason for filing later.

If you appeal a limitation that applies to your access to certain medications under your plan’s drug management program and your plan denies your appeal, your appeal is automatically sent to the IRE. If this happens, you’ll get a written notice about it.

Level 2: Reconsideration by an Independent Review Entity (IRE)

If you disagree with the plan’s redetermination, you, your representative, or your doctor or other prescriber can ask for a standard or fast reconsideration by an IRE. You can’t ask for a fast reconsideration if it’s an appeal about payment for a drug you already got.

How do I ask for a reconsideration?

To ask for a reconsideration by an IRE, follow the directions in the plan’s “Redetermination Notice.” If your plan issues an unfavorable redetermination, it should also send you a “Request for Reconsideration” form that you can use to ask for a reconsideration. If you don’t get this form, call your plan and ask for a copy.

Send your request to the IRE at the address or fax number listed in the “Redetermination Notice” from the plan that’s mailed to you. You’ll get a fast reconsideration if the IRE determines, or your prescriber tells the IRE, that waiting for a standard reconsideration may seriously jeopardize your life, health, or ability to regain maximum function.

Once the IRE gets the request for review, it will send you its decision in a “Reconsideration Notice” within these timeframes:

  • Expedited (fast) reconsideration decision: as quickly as your health condition requires, but no later than 72 hours
  • Standard reconsideration benefit decision: 7 days
  • Standard reconsideration payment decision: 14 days

Note: The IRE may also call itself the “Part D QIC.”

If you disagree with the IRE’s decision in Level 2, you have 60 days after you get the IRE’s decision to request a decision by OMHA, which is Level 3.

Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)

If you’re not satisfied with the IRE’s reconsideration decision, you may ask OMHA for a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, a review of the appeal record by an ALJ or an attorney adjudicator.

A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, but it can be held in person if the ALJ finds that you have a good reason. You can ask OMHA to make a decision without holding a hearing, based only on the information that’s in your appeal record. If you do this, either an ALJ or an attorney adjudicator will review the information in your appeal record and issue a decision. The ALJ or attorney adjudicator may also issue a decision without holding a hearing if, for example, information in your appeal record supports a decision that’s fully in your favor.

To get a hearing or review by OMHA, the amount of your case must meet a minimum dollar amount. The minimum dollar amount for 2026 is $200. The “Reconsideration Notice” may include a statement that tells you if your case is estimated to meet the minimum dollar amount. However, it’s up to the ALJ to make the final decision. You may be able to combine claims to meet the minimum dollar amount.

How do I ask for a hearing?

You must send your request to the OMHA Central Operations. The address is listed in the IRE’s “Reconsideration Notice.” You can ask for a hearing in one of these ways:

  • Fill out a “Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal” form (OMHA-100). You can get a copy by visiting HHS.gov/about/agencies/omha/filing-an-appeal/forms/index.html, or by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  • Submit a written request, which must include:
  • Your name, address, phone number, Medicare Number, and the name of your plan. If you’ve appointed a representative, include their name, address, and phone number.
  • The appeal case number included on the “Reconsideration Notice.”
  • The prescription drug in dispute. Check your “Redetermination Notice” or “Reconsideration Notice” for this information.
  • The reason why you disagree with the reconsideration decision.
  • Any other information that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you’ll submit it.
  • If you’re asking for an expedited (fast) decision, include a statement that explains this.
  • If you’re asking for an expedited (fast) decision, you can make an oral request. Follow the instructions in the IRE’s “Reconsideration Notice” to do this. The ALJ or attorney adjudicator may give you a fast decision if your doctor or other prescriber says, or the ALJ or attorney adjudicator determines, that using the standard 90-day timeframe for making a decision may seriously jeopardize your life, health, or ability to regain maximum function. You can’t ask for (and won’t get) a fast decision if you already got the drug.

If you ask for an expedited (fast) decision, you’ll get a decision as quickly as your health condition requires, but generally no later than 10 days beginning on the day OMHA gets your request for a hearing.

How do I ask for review of my case without a hearing?

To ask that OMHA make a decision without a hearing based only on the information that’s in your appeal record, submit the information required for an ALJ hearing to the IRE and include either:

  • The “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” (Form OMHA-104). You can get a copy by visiting HHS.gov/about/agencies/omha/filing-an-appeal/forms/index.html.
  • A written request, or an oral request in the case of an expedited appeal, stating that you don’t wish to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference), and explaining why you decided to waive the hearing.

Even if you waive the ALJ hearing, a hearing may still be held if the ALJ believes a hearing is necessary to decide your case.

If you have asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and issue a decision.

To learn more about the OMHA review process, visit HHS.gov/about/agencies/omha/ the-appeals-process/level-3/index.html. If you need help filing an appeal with OMHA, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

If you disagree with OMHA’s decision in Level 3, you have 60 days after you get OMHA’s decision to ask for a review by the Medicare Appeals Council (Appeals Council), which is Level 4.

Level 4: Review by the Medicare Appeals Council (Appeals Council)

You can ask that the Appeals Council review your case, regardless of the dollar amount.

How do I ask for a review?

To ask the Appeals Council to review OMHA’s decision in your case, follow the directions in the decision letter you got from OMHA in Level 3. Your request must be sent to the Appeals Council at the address listed in OMHA’s decision. You or your representative can file a request for Appeals Council review in one of these ways:

  • Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form (DAB-101). To get a copy, visit HHS.gov/sites/default/files/ dab101.pdf, or call 1-800-MEDICARE (1-800-633-4227) and ask for a copy. TTY users can call 1-877-486-2048.
  • Submit a written request to the Appeals Council that includes:
  • Your name, address, phone number, Medicare Number, and the name of your plan. Include your representative’s name and address, if you’ve appointed one.
  • The prescription drug in dispute. Check your IRE “Reconsideration Notice” or your decision letter from OMHA for this information.
  • A statement identifying the parts of the ALJ’s decision you disagree with and an explanation of why you disagree.
  • The ALJ appeal case number.
  • If you’re asking for an expedited (fast) decision, include a statement that explains this.
  • If you’re asking for a fast review, you can make an oral request. Follow the instructions in OMHA’s decision notice to do this. The Appeals Council may give you a fast decision if your doctor or other prescriber says, or the Appeals Council determines, that using the standard 90-day timeframe for making a decision may seriously jeopardize your life, health, or ability to regain maximum function. You can’t ask for (and won’t get) a fast decision if you already got the drug.

If you ask for a fast Appeals Council decision, you’ll get a decision as quickly as your health condition requires, but generally no later than 10 days beginning on the day the Appeals Council gets your request, unless that time period is extended.

To learn more about the Appeals Council review process, visit HHS.gov/about/agencies/ omha/the-appeals-process/level-4. If you need help filing a request for Appeals Council review, call 1-800-MEDICARE.

If you disagree with the Appeals Council’s decision in Level 4, you have 60 days after you get the Appeals Council’s decision to ask for Judicial Review by a Federal District Court, which is Level 5.

Level 5: Judicial Review by a Federal District Court

If you disagree with the decision issued by the Appeals Council, you can ask for Judicial Review in Federal District Court. To get a review, the amount of your case must meet a minimum dollar amount. The minimum dollar amount for 2026 is $1,960.

How do I ask for a review?

Follow the directions in the Appeals Council’s decision letter you got in Level 4 to file an appeal in Federal District Court. You should check with the clerk’s office of the Federal District Court for instructions about how to file the appeal.

For more information on the appeals process:

  • Visit Medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans.
  • Call 1-800-MEDICARE.
  • Call your State Health Insurance Assistance Program (SHIP) to get free, personalized health insurance counseling, including help with appeals. To get the phone number for the SHIP in your state, visit shiphelp.org, or call 1-800-MEDICARE.

How do I file a grievance (complaint)?

If you have concerns or problems with your plan that don’t involve requests to provide or pay for drugs, you have the right to file a complaint (also called a “grievance”). For example:

  • You believe your plan’s customer service hours of operation should be different
  • You have to wait too long for your prescription
  • The company offering your plan is sending you materials that you didn’t ask to get and aren’t related to the drug plan
  • Your plan didn’t make a timely decision about a coverage determination in Level 1 and didn’t send your case to the IRE
  • You disagree with the plan’s decision not to grant your request for an expedited (fast) coverage determination or Level 1 appeal (called a “redetermination”)
  • Your plan didn’t give the required notices
  • The plan’s notices don’t follow Medicare rules

If your complaint involves the quality of care you got or are getting, you can file a grievance with your plan and/or your Beneficiary and Family Centered Quality Improvement Organization (BFCC-QIO). You can visit CMS.gov/medicare/quality/ quality-improvement-organizations/family-centered-care or call 1-800-MEDICARE to get the BFCC-QIO’s phone number.

If you want to file a complaint with your drug plan:

  • You must file your complaint within 60 days from the date of the event that led to the complaint.
  • You can file your complaint with the plan over the phone or in writing.
  • You must be told of the plan’s decision generally no later than 30 days after the plan gets the complaint. The timeframe for completing your complaint may be extended by up to 14 days if you ask for the extension, or if your plan justifies the need for the extension and the extension is in your best interest. Your plan will tell you in writing if it decided to take an extension and tell you why.
  • If the complaint relates to a plan’s refusal to make an expedited (fast) coverage determination or redetermination and you haven’t bought or got the drug, the plan must tell you its decision within 24 hours after it gets the complaint.

If the plan doesn’t address your complaint, call 1-800-MEDICARE.

More information on filing a complaint

  • Visit Medicare.gov/providers-services/claims-appeals-complaints.
  • Call your State Health Insurance Assistance Program (SHIP) to get health insurance counseling and help filing a complaint. To get the phone number of the SHIP in your state, visit shiphelp.org, or call 1-800-MEDICARE.

Source and further reading

Medicare Appeals — Centers for Medicare & Medicaid Services. Public domain U.S. government educational material, accessed October 28, 2026. Fynoptic has selected sections, removed print navigation, and reformatted the text for this guide. The agency does not endorse Fynoptic.

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