Navigating Prescription Coverage Determinations

If your doctor or pharmacist tells you a prescription drug isn’t covered, you can ask for an exception, a coverage determination, or an appeal. You can also ask for help finding a different drug.

A standard request has a 72-hour turnaround time. You can also ask for a faster turnaround time of 24 hours.

Types of Coverage Determinations

Your doctor can ask to appeal an initial decision about a coverage determination, also called a request for “redetermination.” Include any information that may be helpful with your redetermination request.

• Ask for your appeal within 60 calendar days after the date of the denial notice.
• We can give you more time if you have a good reason for missing the deadline.
• You, your prescriber, or your appointed representative may ask for a standard or an expedited (faster) appeal.

You may request a prescription drug appeal by phone, fax or mail. Please visit our Contact Us page for more information.

• Prescription Drug Coverage Determination Request Form
• Online Coverage Determination Request Form 
• Prescription Drug Coverage Redetermination Request Form
• Online Coverage Redetermination Request Form

A grievance is a complaint about the quality of care or other services from a Medicare provider. It’s not a complaint about failure to cover or pay for a certain drug. For those concerns, use the determination process outlined above.

Expedited Filing: If you asked for an expedited (fast) coverage determination or redetermination that was denied and you have not yet gotten the drug in dispute, you may file an expedited grievance. File your grievance by phone or fax, and we’ll tell you about our decision within 24 hours of getting your complaint.

You may choose someone to file an appeal or grievance for you. This is called an “appointment of representative.”

• This person can be a relative, friend, sponsor, lawyer, or a doctor.
• A court may also appoint someone.
• You and the person you choose must complete, date, and sign a representative statement.
• The notice or request can also be made in a written letter. If you’re legally not of sound mind or incapacitated, the representative can complete and sign the statement.
• The representative needs to have the correct legal papers or legal authority to sign for you.
• If you choose a lawyer, only you need to sign the representative statement.
• The representative statement must include your name and Medicare claim number.

If you have an issue related to what is covered for pharmacy services, or if you or your appointed representative wish to file a grievance, please call us. Visit our Contact Us page. You may also file a grievance by fax or mail. 

Forms to Appointment a Representative

• CMS Appointment of Representative form 
• Social Security Administration form

You can contact Medicare for more information about benefits and services. This includes basic information about Medicare Advantage Prescription Drug coverage.

To learn about decisions related to medical care, visit Medical Appeals and Grievances.