Office of Medicare Hearings and Appeals (OMHA)

You are reading about Level 1 of the appeals process.

Level 1 Medicare Prescription Drug Plans (Part D)

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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.

You may file an appeal if you are in a Medicare Prescription Drug Plan and you have received a coverage determination from your drug plan sponsor with which you do not agree. At Level 1, your appeal is called a request for redetermination by your prescription drug plan.

You must file your appeal, in writing, unless your drug plan accepts requests by telephone. Contact your Medicare Prescription Drug Plan or check your plan materials about the appropriate process for submitting a request for redetermination. Once your drug plan sponsor has received your request, it has seven (7) days (standard request) to notify you of its decision.

Special Circumstances

Your request for redetermination may be expedited if your drug plan determines or your doctor tells your plan that your health will be seriously jeopardized by waiting for a standard decision. For an expedited redetermination, the plan has 72 hours to notify you of its decision.

If your Level 1 appeal was not decided in your favor, you may wish to file a Level 2 appeal. If your prescription drug plan sponsor is unable to complete its decision within the required timeframe, it is required to forward your appeal to an independent review entity for a Level 2 appeal. In Medicare Part D, a Level 2 appeal is called a reconsideration.

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.