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Medicare Prescription Drug Appeals & Grievances

This section provides specific information of particular importance to beneficiaries receiving Part D drug benefits through a Part D plan.

Use the navigation tool on the left side of this page to link to sub-pages with more detailed information on areas such as grievances, coverage determinations and exceptions, appeals under Part D, and other guidance.

Outreach to Prescribers for Information to Support Coverage Determinations and Redeterminations 

On February 22, 2017, CMS released the HPMS memorandum entitled, “Updated Guidance on Outreach for Information to Support Coverage Decisions.” A copy of the memo is available in the “Downloads” section below.  This memorandum provides clarifying information regarding CMS' expectations for Part D plan sponsors to conduct outreach to prescribers when they do not have all necessary information to make a coverage decision.  The next revision of Chapter 18 of the Medicare Prescription Drug Benefit Manual will be consistent with this guidance.  The information included in the HPMS memorandum supersedes any conflicting guidance in the existing version of Chapter 18, and took effect upon release of the guidance.

Special Open Door Forum: Part D Appeals

Consistent with section 704(f)(1) of the Comprehensive Addiction and Recovery Act (CARA), CMS is seeking input on key aspects of the current Part D appeals process from major stakeholders.  Please see HPMS memo in the “Downloads” section below entitled, "Special Open Door Forum: Part D Appeals Process," inviting stakeholders to provide feedback on the current Part D appeals process on Tuesday, December 20 from 2 - 3:30p.m, EST.

Medicare Prescription Drug Program: Improving Information at the Point of Sale

In late 2015, CMS conducted a pilot study to help identify options for resolving certain Part D point of sale (POS) claim rejections without the enrollee having to request a coverage determination from the plan.  In the pilot, CMS worked with a small number of Part D plan sponsors and pharmacy benefit managers (PBMs) to identify target drugs and to develop and test a proactive process that could resolve the issue by either (1) enabling the plan to authorize payment for the requested drug, or (2) working with the prescriber and obtaining a prescription for an appropriate formulary alternative, without the enrollee having to take any action after the rejected claim.

On January 21, 2016, CMS hosted a conference call where the pilot participants shared information about their experiences in the pilot with other Part D plan sponsors, PBMs and interested stakeholders.  Below in the “Downloads” section are the presentation materials used by the speakers, the written transcript of the call, and, in the “Related Links” section, a link to the audio recording of the call. 

Web Based Training Course Available for Part D

The course covers requirements for Part D coverage determinations, appeals, and grievances found at 42 CFR Part 423, Subpart M and Chapter 18 of the Prescription Drug Benefit Plan Manual. Complete details and a link to the training module can be found on the "Guidance" page (select "Guidance" link on the navigation menu found at the left side of this page).