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Appeals - Level 1: Redetermination from your plan

If you disagree with your plan's initial denial, you can request a redetermination, but you must make your request within 60 days from the date of the coverage determination.

Follow the directions in the plan's initial denial notice and plan materials. You, your representative, your doctor, or other prescriber can ask for a standard or fast redetermination. You can’t request a fast redetermination if it’s an appeal about payment for a drug you already got. Standard requests must be made in writing, unless your plan allows you to file a standard request orally, like by phone. You'll get a fast decision if your plan determines, or your doctor or other prescriber tells your plan, that waiting 72 hours for a decision may seriously jeopardize your:

  • Life
  • Health
  • Ability to regain maximum function
Note

Your doctor or other prescriber can request this level of appeal for you, and you don’t need to appoint them as your representative.

Your plan must accept any written request for a redetermination from you, your representative, your doctor, or other prescriber. A written request to appeal should include:

  • Your name, address, and your Medicare number or member number.
  • The name of the drug you want your plan to cover.
  • Reason(s) why you're appealing.
  • If you've appointed a representative, include the name of your representative and proof of representation.

Send your request along with any other information that may help your case, including medical records.

How long it takes for your plan to respond with a written "Redetermination Notice" depends on the type of request:

  • Expedited (fast) request—as quickly as your health condition requires, but no later than 72 hours
  • Standard service request—7 days

If you disagree with the redetermination decision in level 1, you have 60 days from the date of the decision to request a reconsideration by an Independent Review Entity (IRE).