How to appeal a Medicare Part D drug denial
The short answer
You have 65 days from the date on the drug plan’s denial to ask for a redetermination. Many Part D problems start earlier, with an exception request backed by a statement from your prescriber. If the plan says no again, you or your prescriber must ask the independent review entity yourselves.
Deadlines, decision times and your rights
These are the limits in the federal rules. Your plan can give you more time but not less. If your denial letter prints an earlier date, go by the earlier one.
Deadline to appeal
60 days from when you receive the denial (counted as 65 days from the notice date)
Rule: 42 CFR 423.582(b)
What the rule says
Except as provided in paragraph (c) of this section, a request for a redetermination must be filed within 60 calendar days after receipt of the written coverage determination notice or the at-risk determination under a drug management program in accordance with § 423.153(f).
60 days from when you receive the denial (counted as 65 days from the notice date)
Rule: 42 CFR 423.584(b)
What the rule says
A request for a redetermination must be filed within 60 calendar days after receipt of the written coverage determination notice or at-risk determination notice.
How long they have to decide
7 days after the plan receives your request
Rule: 42 CFR 423.590(a)(2)
What the rule says
If the Part D plan sponsor makes a redetermination that affirms, in whole or in part, its adverse coverage determination or at-risk determination, it must notify the enrollee in writing of its redetermination as expeditiously as the enrollee's health condition requires, but no later than 7 calendar days from the date it receives the request for a standard redetermination.
14 days after the plan receives your request
Rule: 42 CFR 423.590(b)(2)
What the rule says
If the Part D plan sponsor affirms, in whole or in part, its adverse coverage determination, it must notify the enrollee in writing of its redetermination no later than 14 calendar days from the date it receives the request for redetermination.
72 hours after the plan receives your fast request
Rule: 42 CFR 423.590(d)(1)
What the rule says
A Part D plan sponsor that approves a request for expedited redetermination must complete its redetermination and give the enrollee (and the prescribing physician or other prescriber involved, as appropriate), notice of its decision as expeditiously as the enrollee's health condition requires but no later than 72 hours after receiving the request.
72 hours after the plan receives your prescriber's supporting statement
Rule: 42 CFR 423.568(b)
What the rule says
For an exceptions request, the Part D plan sponsor must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its determination as expeditiously as the enrollee's health condition requires, but no later than 72 hours after receipt of the physician's or other prescriber's supporting statement.
24 hours after the plan receives your prescriber's supporting statement
Rule: 42 CFR 423.572(a)
What the rule says
For an exceptions request, the Part D plan sponsor must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its determination as expeditiously as the enrollee's health condition requires, but no later than 24 hours after receipt of the physician's or other prescriber's supporting statement.
The next level
60 days from when you receive the plan's redetermination (counted as 65 days from its date)
Rule: 42 CFR 423.600(a)
What the rule says
The enrollee, or the enrollee's prescribing physician or other prescriber (acting on behalf of the enrollee) must file a written request for reconsideration with the IRE within 60 calendar days after receipt of the written redetermination by the Part D plan sponsor.
60 days from when you receive the IRE's decision (counted as 65 days from its date)
Rule: 42 CFR 423.2002(a)
What the rule says
An enrollee who is dissatisfied with the IRE reconsideration determination has a right to a hearing before an ALJ if— (1) The enrollee files a written request for an ALJ hearing within 60 calendar days after receipt of the written notice of the IRE's reconsideration; and
Your rights along the way
- Missed the deadline? Ask for more time for good cause. The drug plan may accept a late redetermination request if you show good cause. 42 CFR 423.582(c)(1)
- If the drug plan misses its deadline, the case goes to the independent reviewer. A late redetermination counts as a denial and must be forwarded to the Independent Review Entity within 24 hours. 42 CFR 423.590(c)
- The drug plan's denial must give specific reasons. An adverse redetermination notice must state the specific reasons and explain the next appeal step. 42 CFR 423.590(g)
- Present evidence in person or in writing. The drug plan must give you and your prescriber a reasonable chance to present evidence, in person and in writing. 42 CFR 423.586
- Ask the plan to cover a drug not on its list (formulary exception). The plan must cover an off-formulary drug (or waive step therapy / dose limits) if it is medically necessary, backed by your prescriber's statement. 42 CFR 423.578(b)
- What your prescriber's statement must say (formulary exception). Your prescriber must state the drug is medically necessary because alternatives are less effective, failed, or harmful. 42 CFR 423.578(b)(5)
- Ask for a lower copay tier (tiering exception). You can ask to pay the preferred-tier price for a non-preferred drug if your prescriber says the cheaper options won't work as well or would harm you. 42 CFR 423.578(a)(4)
Each rule links to its text in the Electronic Code of Federal Regulations. Checked against the regulation text on November 10, 2026. The Lamdis app works out your dates from these same rules.
Start with the right request
If the drug isn’t on the plan’s list, or it is on a high cost tier, the first step is usually a coverage determination or an exception request. Part D plans with tiered formularies must have an exceptions process (42 CFR 423.578). Your prescriber has to provide a supporting statement for an exception (Medicare.gov).
If that request is denied, you appeal the decision.
Where the 65 days come from
The rule gives 60 calendar days after you receive the denial and presumes you received it 5 days after the date on it (42 CFR 423.582(b)). That is why Medicare.gov says 65 days from the date on the initial denial notice.
The levels
- Redetermination by your plan. 7 days for a drug you haven’t received, 14 days to pay you back, 72 hours if expedited (42 CFR 423.590).
- Independent Review Entity. Unlike Medicare Advantage, this step is not automatic. You or your prescriber must ask in writing within 60 days of receiving the plan’s decision (42 CFR 423.600(a)).
- Hearing with an administrative law judge, then the Medicare Appeals Council, then federal court.
Fast appeals for drugs
If waiting the standard 7 days could seriously harm your health, ask for an expedited appeal. The plan must decide within 72 hours if it agrees, or if your doctor tells the plan, that waiting could do that harm (Medicare.gov).
Drugs Part D won’t cover by law
Part D’s definition of a covered drug leaves out drugs, and uses of drugs, that Medicaid is allowed to exclude under section 1927(d)(2) of the Social Security Act (42 CFR 423.100). That list starts with “agents when used for anorexia, weight loss, or weight gain” (42 U.S.C. 1396r-8(d)(2)(A)). An appeal can’t change that rule. Separately, a temporary CMS program called the Medicare GLP-1 Bridge gives eligible Part D enrollees access to certain GLP-1 drugs between July 1, 2026, and December 31, 2027 (CMS). Our Wegovy and Zepbound pages explain who qualifies and the other uses those drugs are approved for.
Questions people ask
How long do I have to appeal a Part D denial?
65 days from the date on the plan’s denial notice (Medicare.gov).
What is a Part D exception?
A request for the plan to cover a drug that isn’t on its list, or to charge a lower tier’s cost-sharing. Your prescriber must send a supporting statement (42 CFR 423.578).
Is the independent review automatic for drugs?
No. For Part D, you or your prescriber must ask the Independent Review Entity within 60 days of receiving the plan’s redetermination (42 CFR 423.600(a)).
Sources
- Medicare.gov: Appeals in Medicare drug plans
must ask for an appeal within 65 days from the date on the initial denial notice sent by your plan
- eCFR: 42 CFR 423.582, Request for a standard redetermination
a request for a redetermination must be filed within 60 calendar days after receipt of the written coverage determination notice
- eCFR: 42 CFR 423.578, Exceptions process
Each Part D plan sponsor that provides prescription drug benefits for Part D drugs and manages this benefit through the use of a tiered formulary must establish and maintain reasonable and complete exceptions procedures
- eCFR: 42 CFR 423.600, Reconsideration by an independent review entity (IRE)
must file a written request for reconsideration with the IRE within 60 calendar days after receipt of the written redetermination
- eCFR: 42 CFR 423.100, Definitions (Part D drug)
Drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid under sections 1927(d)(2) or (d)(3) of the Act, except for smoking cessation agents.
- Legal Information Institute, Cornell Law School: 42 U.S. Code § 1396r-8 (Social Security Act § 1927)
(A) Agents when used for anorexia, weight loss, or weight gain.
- CMS: Medicare GLP-1 Bridge
The Medicare GLP-1 Bridge is a short-term demonstration run by CMS that will provide eligible Medicare Part D beneficiaries with access to certain GLP-1 drugs between July 1, 2026, and December 31, 2027.
- Medicare.gov: Filing an appeal
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- SHIP Technical Assistance Center: Get Medicare Help from Your Local SHIP Program
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This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.