Redetermination by the Part D Plan Sponsor

If a Part D plan sponsor denies an enrollee’s request, in whole or in part, the enrollee, the enrollee's prescriber, or the enrollee's representative may appeal the decision to the plan sponsor by requesting a standard or expedited redetermination.

How to Request a Redetermination

Redetermination requests must be filed with the plan sponsor within 60 calendar days from the date of the notice of the coverage determination.  Expedited requests may be made verbally or in writing.  Standard requests must be made in writing, unless the enrollee's plan sponsor accepts verbal requests (an enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts verbal requests).

Written requests may be made by using the Model Redetermination Request Form (see the link in the "Downloads" section below), a request form developed by a plan sponsor or other entity, or any other format.

How a Plan Sponsor Processes Redetermination Requests

Once the request is received by the plan sponsor, it must make its decision and provide written notice of its decision as quickly as the enrollee's health requires, but no later than 72 hours (for expedited requests) or 7 calendar days (for standard requests) from receipt of the request.  For payments, plan sponsors must provide written notice of their decision (and make payment, when appropriate) within 14 calendar day after receiving a request. For expedited redeterminations, initial notice may be provided verbally so long as a written follow-up notice is mailed to the enrollee within 3 calendar days of the verbal notification.

If the decision is unfavorable, the decision will contain the information an enrollee needs to file a request for a reconsideration by the Independent Review Entity (IRE).  If the decision relating to an at-risk determination under a drug management program is unfavorable to the enrollee, in whole or in part, the plan sponsor must submit the case file and its decision for automatic review by the Part D IRE.

For more information on redeterminations and appointing a representative, see section 50 and section 20 (respectively) of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, in the "Downloads" section below.

Detailed information about reconsiderations by the IRE, or any other level of appeal, can be accessed using the left navigation menu on this page.