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."
A list of specific contacts at Part D sponsors can be found at: /Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/PartDContacts
Use the navigation menu on the left side of this page to link to web pages with more detailed information on Part D such as grievances, coverage determinations and exceptions, appeals, and other guidance.
Web Based Training Course Available for Part D
The course covers requirements for Part D coverage determinations, appeals, and grievances. Complete details and a link to the training module can be found on the "Training" page (link on the left navigation menu on this page).