If your Medicare drug plan decides against you in level 1, it will send you a written decision. If you disagree with the decision, you can request a standard or fast reconsideration by an Independent Review Entity (IRE). Your representative, doctor, or other prescriber can also request a reconsideration for you.
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 this form to ask for a reconsideration.
Your doctor or other prescriber can request this level of appeal for you. You don’t need to appoint them as your representative.
How long it takes the IRE to send you its decision 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 can request an Administrative Law Judge (ALJ) hearing. You have 60 days from the date of the IRE's decision to request the ALJ hearing.