Sold by private insurance carriers, Medicare Part D plans help pay for outpatient prescription drugs. Each Part D plan has its own formulary, which is a list of drugs the plan covers. So what should you do if your Medicare Part D plan denies coverage of a new medication—or one you take regularly?

If you were told your drug has been denied coverage, and you disagree with this decision, you have the right to appeal. Understanding how to effectively appeal a denial can make a big difference in ensuring you have access to the medications you need to manage your conditions and stay healthy. The tips below were developed for us by the Medicare Rights Center, and explain the five levels of appeal rights you have regarding Part D coverage denials.

How do I appeal a Medicare Part D denial?

The first step is to contact your Part D plan provider to find out why you were denied coverage for the drug. There are many reasons a plan may deny coverage, but here are some more common ones:

• Prior authorization: You must get prior approval from the plan before it will cover a specific drug.
• Step therapy: The plan requires you try a different or less expensive drug first.
• Quantity limits: The plan only covers a certain amount of a drug over a certain period, such as 30 pills per month.
• Off-formulary: The drug is not on the plan's list of covered drugs.

Before you start the formal appeal process, you will need to send the plan an exception request or a request for a coverage determination. You should contact your plan to find out where to send it and what information is required. You may also want to ask your doctor for help with this.

The plan will give you a decision within 72 hours. If the exception request is approved, your drug will be covered. If not, you can proceed with a formal appeal using the process outlined below.

Steps in the appeal process

If your exception request is denied, or the response to a coverage determination request is unfavorable, your plan should send you a Notice of Denial of Medicare Prescription Drug Coverage. Then, you can begin your appeal. The appeal process is outlined below.

1. Appeal with the plan: You have 60 days from the date listed on the notice to file an appeal with the plan. You should follow the directions on the notice. The plan should issue a decision within seven days. If the plan approves the appeal, your drug will be covered. If it is denied, you can proceed to Step 2.
2. Appeal with the Independent Review Entity (IRE): You must send their appeal to the IRE within 60 days of the date listed on the plan denial. The IRE should issue a decision within seven days. If you are filing an expedited appeal, a decision should be issued by the IRE within 72 hours. If the IRE approves the appeal, your drug will be covered. If not, you can proceed to Step 3.
3. Appeal with the Office of Medicare Hearings and Appeals (OMHA): If the appeal is denied and the drug is worth at least $180 in 2024, you can choose to appeal to the OMHA level. You must submit the appeal within 60 days of the date on your IRE denial letter. The OMHA should issue a decision within 90 days (10 days for an expedited appeal). If the appeal to the OMHA level is successful, your drug will be covered. If not, you can proceed to Step 4.
4. Appeal to the Council: The appeal to the Council must be sent within 60 days of the date on your OMHA level denial letter. The Council should issue a decision within 90 days (10 days for an expedited appeal). If the appeal to the Council is successful, your drug will be covered. If not, you may be able to proceed to Step 5.
5. Appeal with the Federal District Court: If the appeal is denied and your drug is worth at least $1,840 in 2024, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to issue a decision about the appeal. If the appeal is successful, your drug will be covered. You may want to consult an attorney to decide whether it makes sense to appeal in District Court.

Tips for a successful appeal

• Ask your doctor to write a letter of support addressing the plan's reasons for not covering the needed drug. Doctors can confirm medical necessity and may be able to work closely with you through the appeals process.
• You may wish to contact a lawyer or legal services organization if you need help with steps after the IRE—but it is not required.
• Keep records of the conversations you have with your plan, as well as any documents you receive from your plan, your provider, or entities at higher levels of the appeals process.
• Be persistent. Each level of an appeal is an independent decision; therefore, an appeal denied at a lower level may be approved at higher levels without any new or additional information.