If your Medicare drug plan decides against you in level 1, it will send you a written decision. If you disagree with the plan's redetermination, you, your representative, your doctor, or your other prescriber can request a standard or fast reconsideration by an Independent Review Entity (IRE). You can’t request a fast redetermination if it’s an appeal about payment for a drug you already got. Follow the directions in the plan’s "Redetermination Notice." If your plan issues an unfavorable redetermination, it should also send you a "Request for Reconsideration" form you can use to ask for a reconsideration.
Your doctor or other prescriber can request this level of appeal for you, and you don’t need to appoint them as your representative.
How long it takes the IRE to send you its decision in a written "Reconsideration 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
Some IREs call themselves “Part D QICs.”
If you disagree with the IRE's decision in level 2, you have 60 days from the date of the IRE's decision to request an Administrative Law Judge (ALJ) hearing.