How to appeal a Medicare Part D drug plan denial
You have 65 days from the date on the denial notice to ask your plan to reconsider. A fast appeal is decided within 72 hours if waiting could harm your health.
Who decides
You ask the drug plan to look again first. Your prescriber can ask for you and can support an exception request.
Steps
- Level 1, redetermination: ask the plan within 65 days of the date on the denial notice.
- The plan decides within 7 days for a drug you have not got yet, 14 days for payment, or 72 hours for a fast appeal.
- Level 2, reconsideration by an Independent Review Entity: within 60 days of the level 1 decision.
- Levels 3 to 5: a judge hearing, the Medicare Appeals Council, then federal court.
Deadlines
| Step | File within | Decision due |
|---|---|---|
| Level 1 redetermination | 65 days from the date on the denial notice | 7 days for a drug, 14 days for payment, 72 hours if fast |
| Level 2 Independent Review Entity | 60 days from the level 1 decision |
Dates are a guide. Count from the date on your notice, or the day you received it where the rule says so, and use any date printed on your notice if it differs. File early and keep proof of when you sent it.
If it is urgent
If waiting could seriously harm your health, ask for an expedited (fast) appeal and have your doctor say it is urgent. For private plans you can ask for an urgent external review at the same time.
Where to get free help
- 1-800-MEDICARE (1-800-633-4227).
- Your State Health Insurance Assistance Program (SHIP): https://www.shiphelp.org/
What to send with your appeal
- A copy of the denial notice or Explanation of Benefits.
- A letter from your doctor explaining why the care is needed (a letter of medical necessity).
- Relevant medical records, test results and notes on treatments already tried.
- The pages of your plan documents that support coverage.
- Notes of phone calls: date, time, who you spoke to and what they said.
- Keep copies of everything, send it in a way you can track, and ask the plan to confirm it arrived.
Draft an appeal letter for the reason on your notice: not medically necessary, not an emergency, experimental, out of network, no prior authorization, a coding error or another reason.
Quick answers
- How long do I have to appeal?
- You have 65 days from the date on the denial notice to ask your plan to reconsider. A fast appeal is decided within 72 hours if waiting could harm your health.
- Who decides my appeal?
- You ask the drug plan to look again first. Your prescriber can ask for you and can support an exception request.
- What if my case is urgent?
- If waiting could seriously harm your health, ask for an expedited (fast) appeal and have your doctor say it is urgent. For private plans you can ask for an urgent external review at the same time.
General information, not legal or medical advice. Rules differ by plan and state, so check the dates and instructions on your own denial notice, and talk to your doctor about the medical side. Free help is available from your state and the contacts listed.
Sources
- https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals
- https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans
Ask Appeal My Claim yourself
Enter the date on your denial notice and get an approximate file-by date for each step. Open Appeal My Claim, free, no sign-up.
In Claude or any app that takes MCP connectors, add https://goodturn-mcp.pages.dev/appealmyclaim/mcp and ask: “How long do I have to appeal a medicare part d drug plans denial?”