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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.

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).