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Appeals Overview

If a plan sponsor issues an unfavorable coverage determination, the decision may be appealed through the Part D appeals process.

There are five successive levels of appeal in the Medicare Part D program.

  1. Redetermination by the Part D Plan Sponsor
  2. Reconsideration by the Independent Review Entity
  3. Hearing by an Administrative Law Judge or Attorney Adjudicator
  4. Review by the Medicare Appeals Council
  5. Review by a Federal District Court

A decision may be appealed to the next level of appeal when the lower appeal entity issues a decision that is unfavorable to the enrollee.  Each unfavorable decision will contain the information needed to file an appeal request.

Use the navigation tool on the left side of this page to link to subpages that contain detailed information about each of the five levels of appeal.

A list of specific contacts at Part D sponsors can be found at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/PartDContacts.html

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