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Redetermination by the Part D Plan Sponsor

If a Part D plan sponsor issues an adverse coverage determination, the enrollee, the enrollee's prescriber, or the enrollee's representative may appeal the decision to the plan sponsor by requesting a standard or expedited redetermination.

For more information about appointing a representative, see section 10.4 in Chapter 18 of the Prescription Drug Benefit Manual.  You may view Chapter 18 of the Prescription Drug Benefit Manual by clicking on the link in the "Downloads" section below.

How to Request a Redetermination

Redetermination requests must be filed with the plan sponsor within 60 calendar days from the date of the notice of the coverage determination.

Expedited requests may be made orally or in writing.

Standard requests must be made in writing, unless the enrollee's plan sponsor accepts oral requests (an enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral requests).

Written requests may be made by using the Model Redetermination Request Form (see the link in the "Downloads" section below), a request form developed by a plan sponsor or other entity, or any other format.

How a Plan Sponsor Processes Redetermination Requests

Once the request is received by the plan sponsor, it must make its decision and provide written notice of its decision as quickly as the enrollee's health requires, but no later than 72 hours (for expedited requests) or 7 calendar days (for standard requests) from receipt of the request.  For expedited redeterminations, initial notice may be provided orally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the oral notification.  .

If the decision is unfavorable, the decision will contain the information an enrollee needs to file a request for a reconsideration by the Independent Review Entity.

Use the navigation tool on the left side of this page to link to subpages that contain detailed information about reconsiderations by the Independent Review Entity or any other level of appeal.

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

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