Office of Medicare Hearings and Appeals (OMHA)

Who to Appeal to for Level 2 Medicare Prescription Drug Plans (Part D)

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You will be notified by mail of the outcome of your Level 1 appeal (called a redetermination in Medicare Part D) by your Medicare prescription drug plan sponsor. If you are dissatisfied with the outcome of the redetermination, you may file a Level 2 appeal.

An Independent Review Entity (IRE), retained by CMS, will conduct the Level 2 appeal. In Medicare Part D, a Level 2 appeal is called a reconsideration. IREs have their own physicians and other health professionals to independently review and assess the medical necessity of the prescriptions and items pertaining to your case. The IRE will take into consideration the views of your prescribing physician. File a Level 2 written appeal within 60 days of receiving the notice of redetermination. You will file your request with the IRE named on the notice.

In most cases, you will receive notice of the IRE's decision within 7 days after the IRE's Medicare Part D reconsideration request. The notice will contain detailed information about your right to appeal to OMHA (Level 3) if you are dissatisfied with the IRE’s decision.

Special Circumstances

You may request an expedited reconsideration for Part D coverage decisions. Your request will be expedited if the Independent Review Entity (IRE) determines or your doctor tells the IRE that your life or health will be seriously jeopardized by waiting for a standard decision. If your request is expedited, the IRE has 72 hours to notify you of its decision.

For more information about filing a Level 2 appeal, visit the "Appeals and Grievance" section of Medicare.gov.

If your Level 2 appeal was not decided in your favor and you disagree with the decision, you may file a Level 3 appeal with OMHA if the amount remaining in controversy is $120 or more (2008). Note you may be able to combine claims to meet the minimum dollar amount.

You can download the Chart of the Appeals Process for Medicare Prescription Drug Plans - Part D [ PDF - 56KB, DOC - 52KB]. The chart contains the overview for the entire appeals process for Medicare Part D.

Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlements and IRMAA appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.