Step: |
How to Request: |
Do This Within: |
Decision Within: |
Request a coverage determination (specifically: formulary exception) |
Call or write to your plan. Your health care provider must explain why you need the specific medicine. |
No time requirement. |
72 hours of receiving health care provider's satement (24 hours for expedited request) |
Request a redetermination |
Write to your plan and request a redetermination. |
60 days of formulary exception denial. |
7 days (72 hours for expedited request. |
Request a reconsideration. |
Write to the independent review entity (RIE) noted in your redetermination denial letter. |
60 days of denial of redetermination request for coverage. |
7 days (72 hours for expedited request). |
Appeal to the Administrative Law Judge (ALJ). |
Follow steps in reconsideration letter. |
60 days of denial of redetermination request for coverage. |
No time requirement. |
Appeal to the Medicare Appeals Council (MAC). |
Follow steps in ALJ letter. |
60 days of denial from the ALJ. |
No time requirement. |
File suit in Federal District Court. |
Follow steps in MAC letter. |
60 days of denial from the MAC. |
Depends on court schedule. |
