People With Medicare
Step 1 - Redetermination
To file an appeal, ask your Plan D sponsor for what is called a "redetermination." You are asking your plan to reconsider the exception you asked for.
How much time do I have to ask for a redetermination?
You have 60 calendar days from the time the plan told you it was denying your exception.
Who can ask for a redetermination?
You can file for a redetermination yourself, or you can appoint someone to do it for you. Your doctor can also ask for a redetermination for you. If you appoint someone to do it for you, it is a good idea to submit Medicare's "Appointment of Representative" form with your redetermination request.
How do I ask for a redetermination?
You must ask your plan for a redetermination. Plans have different rules, so ask your plan what their process is. They may have special rules or a specific form you need to use. Generally, you can make that request by writing or calling your plan.
If you write to your plan, you should include this information:
- your name
- your address
- your Medicare number
- the name of the prescription drug you want your plan to cover
- the reasons why you are appealing your plan's decision about your exception
- any written documents that you think would support your request, such as a letter from your doctor, or your medical records
- an "Appointment of Representative" form if you are appointing someone to appeal for you
- your signature or your appointed representative's signature.
How long will it take my plan to respond to my request?
For standard requests, your plan will tell you the decision within 7 calendar days of receiving your request. If you or your doctor make an expedited request, your plan must tell you the decision in 72 hours.
If your plan does not reach a decision within these time frames, your appeal will automatically be sent to the next level, called reconsideration.
After I file my redetermination, what happens next?
Your plan will send you a letter letting you know the decision.
If your plan decides to cover your medicine, then you do not need to do anything more.
If your plan decides not to cover your medicine, you can move on to Step 2. In Step 2, you would file a request for reconsideration by an Independent Review Entity.