Medicare Part D appeals and grievances

What is a Part D appeal?

If your Part D plan denies coverage for a drug, refuses to pay the amount you think it should, or imposes a restriction (like prior authorization or step therapy) that prevents you from getting your medication, you have the right to appeal. The appeals process exists to protect you from incorrect or unfair coverage decisions.

Appeals are different from grievances. An appeal challenges a coverage decision. A grievance is a complaint about something else — like rude customer service, pharmacy access problems, or how the plan handled an appeal.

When you might need to appeal

• Your plan denies coverage for a drug because it's not on the formulary
• The drug requires prior authorization and your plan denies the request
• Step therapy requires you to try a different drug first, but you've already tried it or it's not safe for you
• Quantity limits restrict how much medication you can get, but your doctor prescribed more
• The plan charges you more than you think you should pay
• The plan refuses reimbursement for a drug you already paid for

The five levels of appeals

Part D appeals have five potential levels. Most appeals are resolved at the first or second level.

Level 1: Coverage redetermination

Ask your Part D plan to reconsider its decision. You have 60 days from the original denial to file. The plan must respond within 72 hours for standard requests or 24 hours for expedited requests (when waiting could harm your health).

Level 2: Independent review by an outside organization

If level 1 is denied, you can ask for review by an Independent Review Entity (IRE) — an outside organization not affiliated with your plan. Same timeframes apply.

Level 3: Administrative Law Judge (ALJ) hearing

If the dollar amount in dispute is at least $190 (2026), you can request a hearing before an Administrative Law Judge.

Level 4: Medicare Appeals Council review

You can request review by the Medicare Appeals Council if the ALJ rules against you.

Level 5: Federal court review

Final appeal level. Requires a minimum dollar amount (about $1,900 in 2026) and an attorney is strongly recommended.

How to request a formulary exception

A formulary exception is a specific type of appeal that asks your plan to cover a drug that isn't on its formulary. To get an exception, your prescriber must provide a statement that the alternative drugs on the formulary either:

• Wouldn't be as effective for your condition, or
• Would cause you adverse effects

You can also request a tier exception — asking your plan to charge you the lower copay of a different tier — if your doctor states the lower-tier drugs would be less effective or cause adverse effects.

How to file an appeal

Each Part D plan has its own appeals process, but they all follow CMS rules. Here's the general process:

1. Get a written denial. Ask the pharmacy or your plan for a "Notice of Denial of Medicare Prescription Drug Coverage." This document explains why you were denied and how to appeal.
2. Get supporting documentation. Have your doctor write a letter explaining why you need this specific drug. Include any medical records that support your case.
3. Submit your appeal in writing. Use the form your plan provides, or write a letter. Include your name, member ID, the drug name, the denial date, and why you're appealing.
4. Request expedited review if needed. If waiting could seriously harm your health, ask for an expedited (fast) decision. The plan must respond within 24 hours.
5. Track everything. Keep copies of all correspondence and note the dates of every interaction.

Filing a grievance

For complaints that don't involve a coverage decision — pharmacy network issues, customer service problems, plan procedures — file a grievance with your plan. You generally have 60 days from the incident to file. Plans must respond within 30 days for standard grievances or 24 hours for expedited.

If your plan keeps denying coverage, consider switching

If your Part D plan repeatedly denies drugs you need, you may be on the wrong plan. During the next Annual Enrollment Period, compare plans that cover your specific medications on PlanMatch, or a licensed Medicare agent can help you find a plan with a more favorable formulary for free.

Tips for a successful appeal

• Don't delay. You have 60 days from the denial to file the first level appeal.
• Get your doctor involved early. A statement from your prescriber explaining medical necessity is the most important piece of evidence.
• Be specific. State exactly which drug, the dose, why alternatives won't work, and what evidence supports your case.
• Request expedited review if appropriate. Don't accept a 72-hour timeline if waiting could harm you.
• Keep going. Many denials are reversed at higher appeal levels. Don't give up if your level 1 appeal is denied.

Frequently asked questions