Medicare Prescription Drug Appeals & Grievances
This page discusses the enrollees right to request a Part D coverage determination, appeal or file a grievance/complaint.
Individuals who represent enrollees may either be appointed or authorized to act on behalf of the enrollee in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeals process. For more information about appointing a representative, see section 20 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, using the link in the "Downloads" section below.
UPDATED PART D APPEALS GUIDANCE
August 3, 2022: The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance has been updated to incorporate the new Dismissal regulations, other revised provisions of CMS-4190, and clarifications of existing language. The updated guidance will be effective immediately. Questions related to the guidance or appeals policy may be submitted to the Division of Appeals Policy at https://appeals.lmi.org.
To access the guidance document, click on the link below titled "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance" under "Downloads."
May 3, 2022: The new Medicare Parts C & D IRE Decision Database can be located at https://www.cms.gov/qic-decision-search.
The FAQs address common questions we have received from MA plans and Part D plan sponsors and is available in the “Downloads” section below.
The model dismissal notices are available on the "Plan Sponsor Notices and Other Documents" page, using the link on the left navigation menu on this page.
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).
Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (PDF)
Medicare Part D Coverage Determinations/Appeals Flowchart (PDF)
Dismissal and Withdrawal FAQs (PDF)