Key takeaways
  • A Part D appeal has five levels — redetermination by your plan, independent reconsideration, an ALJ hearing, the Appeals Council, and federal court.
  • Standard Level 1 appeals must be decided within 7 days; expedited appeals take 72 hours when your health is at risk.
  • You must file within 60 days of the denial notice, and every appeal costs you nothing to file.

Your pharmacy says your Part D plan won't cover a prescription. What exactly can you do about it — and how fast does the plan have to answer? Medicare gives you a formal five-level appeal process with real deadlines the plan must meet.

Step zero: get the denial in writing

When the pharmacy can't fill your prescription, that is not yet an official denial. You (or your doctor) must first ask the plan for a coverage determination — a written decision explaining what the plan will cover. The plan must decide within 72 hours for a standard request, or 24 hours if your doctor says you have an urgent need. If the answer is no, that written denial notice triggers your appeal rights — and it will include instructions for the next step.

Level 1: Redetermination by your plan

Your first formal appeal is a redetermination, reviewed by your own drug plan. Here are the rules that matter:

To request an expedited redetermination, your plan must agree — or your doctor must tell the plan — that waiting would seriously jeopardize your health or ability to function.

Level 2: Independent reconsideration (IRE)

If the plan upholds its denial, you can ask for a reconsideration by an Independent Review Entity — a third-party organization contracted by CMS with its own physicians and no affiliation to your plan. File your written request within 60 days of the redetermination denial, using the IRE named on the notice. The IRE has 7 days for a standard case, 72 hours for an expedited one. Because a fresh, independent clinician reviews the medical evidence — free of the plan's internal coverage policies — this level often carries more weight than the redetermination. And the appeal costs you nothing to file at Levels 1 and 2.

Levels 3–5: ALJ hearing, Appeals Council, federal court

Beyond the IRE, the remaining levels mirror the rest of Medicare's appeal system, with annual dollar thresholds adjusted by CMS:

How to make your appeal stronger

You do not need a lawyer to win the early levels. What wins appeals is evidence — follow these steps:

  1. Get your prescriber on board. A supporting statement from your doctor explaining why the drug is medically necessary — and why the plan's preferred alternative would be less effective or cause side effects — is the single most persuasive thing you can submit.
  2. Include everything, every time. Attach lab results, failed medication trials, allergy documentation, and the written denial notice itself. You can add new evidence at each level.
  3. Appoint a representative if needed. A family member or your doctor can file on your behalf with your written permission (Form CMS-1696).
  4. Track every deadline. Each level gives you 60 days to file — appeal decisions arrive faster than most people expect, so don't let a filing window close.
  5. Get free help. Call 1-800-MEDICARE (1-800-633-4227) or contact your local SHIP counselor (find yours at shiphelp.org) for one-on-one guidance — it's free, unbiased help from trained volunteers.

If you paid out of pocket while the appeal was pending and later win, you can seek reimbursement from the plan for the covered cost.

Bottom line: A Part D denial is a decision you can challenge through five formal levels — starting with a redetermination your plan must answer within 7 days (72 hours if your health is at risk) — so always get the denial in writing, file within 60 days, and let your doctor's evidence do the heavy lifting.