People With Medicare
What is an appeal?
An appeal is a way for you to challenge a plan's decision about your drug coverage. You can make an appeal if the plan says no when you ask for an exception.
If your plan denies your exception, you may want to appeal if:
- a drug you need is not on your plan's list of covered drugs, or formulary, OR
- you need a drug that your plan has set limits on or has special rules about, OR
- a drug you need costs more than you can afford.
How do I file an appeal?
There are five steps to the appeals process. You must follow the steps in order, but you might not have to go through all five steps. You might receive a decision in your favor before then.
Steps of the Appeals Process
- Step 1: Redetermination
- Step 2: Reconsideration
- Step 3: Hearing with an Administrative Law Judge
- Step 4: Review by the Medicare Appeals Council
- Step 5: Review by a federal court