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Medicare Prescription Drug Appeals & Grievances

UPDATED PART D APPEALS GUIDANCE

February 22, 2019: As part of an initiative to streamline the Part C and Part D appeal and grievance processes, CMS has merged Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one Parts C & D appeals guidance document. The combining of these chapters will better align Part C and Part D appeals policy, identify key differences between the two, provide clearer interpretation of current policy, and update guidance based on the Part C and D 2019 regulation. To access the guidance document and a list of frequently asked questions, click on the link below titled "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance" and “Part C & D Appeals Guidance Frequently Asked Questions (FAQs)” under "Downloads."

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

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

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.

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 Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance. Complete details and a link to the training module can be found on the "Guidance" page (select "Guidance" link on the left navigation menu found on this page).  

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