Medicare Prescription Drug Appeals & Grievances

What's New

UPDATED PART D APPEALS GUIDANCE

July 19, 2024: The Parts C and D Enrollee Grievance, Organization/Coverage Determinations and Appeals Guidance has been updated to incorporate recent changes to 42 CFR § 422.566(d), to include certain terminology changes, to clarify who may act or be appointed as a representative, and to indicate that enrollees, their representatives, or providers on behalf of enrollees, have the right to voluntarily request plan approval on any service, item, or Part B drug which they believe are, or should be, covered by the plan. 

The updated guidance will be effective immediately.  Questions related to the guidance or appeals policy may be submitted to the Division of Appeals Policy at https://appeals.lmi.org. 

To access the guidance document, see the link to "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance" in the “Downloads” section below.

Prescription Drug Grievances, Coverage Determinations and Appeals

Medicare Prescription Drug plans must meet the requirements for grievance, coverage determination, and appeals processing under the Part D regulations found at 42 CFR Part 423, Subpart M.  For more information regarding grievances and various levels of appeal, please see the links on the left navigation menu on this page. Additional guidance is also in the "Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance," in the “Downloads” section below.

Use the navigation menu on the left side of this page to link to web pages with more detailed information on Part D such as grievances, coverage determinations and exceptions, appeals, and other guidance.

Web Based Training Course Available for Part D

The course covers requirements for Part D coverage determinations, appeals, and grievances. Complete details and a link to the training module can be found on the "Training" page (link on the left navigation menu on this page).  

Questions?

Questions regarding organization determinations, appeals and grievances can be submitted at: https://appeals.lmi.org