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Medicare Prescription Drug Appeals & Grievances

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.

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.

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).  

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