Exceptions, Appeals and Grievances

Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can reach us at 1-800-353-3765 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. Our Plan accepts grievances orally or in writing, provided the grievance is submitted to us within 60 calendar days after the event or incident that precipitated (led to) the grievance. Once we receive your grievance, we will look into your concerns, including obtaining any additional information necessary to fully review our grievance.

To file a grievance in writing send your request to:

Elderplan, Inc.
Attn: Appeals & Grievances
55 Water Street 46th Floor, Suite 202
New York, NY 10041

Or fax it to: 718-765-2027

You may also file your grievance directly through Medicare by clicking here: English | Español.

To receive information on the total number of grievances, appeals, and exceptions filed with Elderplan, please contact Member Services at 1-800-353-3765 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week.

A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Elderplan, our network providers, or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you may file a grievance if you are unhappy with the quality of the care you have received, are unhappy with how our member services has treated you, or if you have a problem with waiting times when you fill a prescription.

For quality of care complaints, you may also complain to Livanta. Complaints concerning the quality of care received under Medicare may be acted upon by the plan sponsor under the grievance process, by an independent organization called Livanta, or by both. For example, if an enrollee believes his or her pharmacist provided the incorrect dose of a prescription, the enrollee may file a complaint with Livanta in addition to or in lieu of a complaint filed under the plan sponsor’s grievance process. For any complaint filed with Livanta, the plan sponsor must cooperate with Livanta in resolving the complaint.

Quality of care complaints filed with Livanta must be made in writing. An enrollee who files a quality of care grievance with Livanta is not required to file the grievance within a specific time period.

You can contact Livanta at:
Livanta BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701
Phone: 866-815-5440
Fax: 833-868-4056
TTY: 866-868-2289 TTY
Website: www.livantaqio.com

Medicare Ombudsman: English | Español

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want at the contact information listed below. You, your doctor, or your representative can do this.

Call:
1-800-353-3765 8 a.m. – 8 p.m., 7 days a week
TTY: 711

Fax:
718-765-2027

Write:
Elderplan, Inc.
55 Water Street 46th Floor, Suite 202
New York, NY 10041

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 14 calendar days after we receive your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. A fast coverage decision means we will answer within 72 hours. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.

To get a fast coverage decision, you must meet two requirements: (1) You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.) (2) You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no.

If we say no to your request for coverage for medical care, you decide if you want to make an appeal. To start an appeal you, your doctor, or your representative, must contact us. If you are asking for a standard appeal, make your standard appeal in writing by submitting a request or calling us at the contact information listed below. If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. If you are asking for a fast appeal, make your appeal in writing or call us. You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.

Call:
1-800-353-3765 8 a.m. – 8 p.m., 7 days a week
TTY: 711

Fax:
718-765-2027

Write:
Elderplan, Inc.
55 Water Street 46th Floor, Suite 202
New York, NY 10041

If your health requires it, ask for a “fast appeal” (you can make a request by calling us). If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.” The requirements and procedures for getting a “fast appeal” are the same as those for getting a “fast coverage decision.” To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal. When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.

If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal.

Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a determination whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of preferred drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

If you have problems getting the prescription drugs you believe we should provide, you can request a coverage determination. We use the word “provide” in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting.

If your doctor or pharmacist tells you that Elderplan will not cover a prescription drug, you should contact us and ask for a coverage determination. The following are examples of when you may want to ask us for a coverage determination:

• If you are not getting a prescription drug that you believe may be covered by Elderplan.
• If you have received a Part D prescription drug you believe may be covered by Elderplan while you were a member, but we have refused to pay for the drug.
• If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of preferred drugs (also called a formulary). You can request an exception to our formulary.
• If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the co-payment we require you to pay for a drug.
• If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
• If there is a limit on the quantity (or dose) of the drug, and you disagree with the requirement or dosage limitation.
• If there is a requirement that you try another drug before we will pay for the drug you are requesting.
• If you bought a drug at a pharmacy that is not in our network, and you want to request reimbursement for the expense.

The purpose of this section is to give you more information about how to request a coverage determination or appeal a determination by us not to cover or pay for all or part of a drug, vaccine or other Part D benefit.

When we make a coverage determination, we are giving our interpretation of how the Part D prescription drug benefits that are covered for members of Elderplan apply to your specific situation. Elderplan makes a coverage determination about your Part D prescription drug or about paying for a Part D prescription drug you have already received. The coverage determination made by Elderplan is the starting point for dealing with requests you may have about covering or paying for a Part D prescription drug. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you should contact Elderplan and ask us for a coverage determination. With this determination, we explain whether we will provide the prescription drug you are requesting or pay for a prescription drug you have already received. If we deny your request (this is sometimes called an “adverse coverage determination”), you can appeal the determination by going on to Appeal Level 1. If we fail to make a timely coverage determination on your request, it will be automatically forwarded to the independent review entity, Appeal Level 2, for review.

The following are examples of coverage determinations:

• You ask us to pay for a prescription drug you have already received. This is a request for a coverage determination about payment. You can call us at 1-866-490-2102, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to get help in making this request.
• You ask for a Part D drug that is not on Elderplan’s list of preferred drugs (also called a formulary). This is a request for a “formulary exception.” You can call us at 1-866-490-2102, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to ask for this type of determination.
• You ask for an exception to our plan’s utilization management tools — such as dosage limits, quantity limits or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. You can call us at 1-866-490-2102, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to ask for this type of determination.
• You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a “tiering exception.” You can call us at 1-866-490-2102 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to ask for this type of determination.

You ask that we reimburse you for a purchase you made from an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician’s office, will be covered by the plan. You can call us at 1-866-490-2102, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630), to make a request for payment or coverage for drugs provided by an out-of-network pharmacy or in a physician’s office.

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement, Appointment of Representative, must be sent to us at:

CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673.

You also have the right to have an attorney ask for a coverage determination on your behalf. You can contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

Learn how to appoint a representative.

Do you have a request for a Part D prescription drug that needs to be decided more quickly than the standard timeframe? A determination about whether we will cover a Part D prescription drug can be a “standard” coverage determination that is made within the standard timeframe (typically within 72 hours), or it can be a “fast” coverage determination that is made more quickly (typically within 24 hours). A fast determination is sometimes called an “expedited coverage determination.”

You can ask for a fast determination only if you or your doctor believe that waiting for a standard determination could seriously harm your health or your ability to function. Fast determinations apply only to requests for Part D drugs that you have not received yet. You cannot get a fast determination if you are requesting payment for a Part D drug that you already received.

To ask for a standard determination, you, your doctor or your appointed representative should call us at 1-866-490-2102, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630). Or, you can mail a written request,or completed Request for Coverage Determination Form to:

CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673.

You, your doctor or your appointed representative can ask us to give a fast determination (rather than a standard determination) by calling us at 1-866-490-2102, 24 hours a day, 7 days a week (for TTY, call 1-866-763-9630). Or, you can mail a written request or completed Request for Coverage Determination Form to:

CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673.

Be sure to ask for a “fast,” “expedited,” or “24-hour” review.

• If your doctor asks for a fast determination for you or supports you in asking for one, and the doctor indicates that waiting for a standard determination could seriously harm your health or your ability to function, we will automatically give you a fast determination.
• If you ask for a fast coverage determination without support from a doctor, we will decide if your health requires a fast determination. If we decide that your medical condition does not meet the requirements for a fast coverage determination, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast determination. The letter will also tell you how to file a grievance if you disagree with our determination to deny your request for a fast review. If we deny your request for a fast coverage determination, we will give you our determination within the 72-hour standard timeframe.

Certain drugs require supporting documentation from your physician (non-formulary and tiering exceptions, prior authorizations, step therapies, quantity limits). Your physician may use the available forms (or ANY other written forms) to assist in this process.

Member Reimbursement Form
Prescription Reimbursement Claim Form
Prescription Drug Determination Claim Form
Redetermination of Prescription Drug Denial Form

Physicians assisting with coverage determinations may also use the Prescription Drug Determination Claim Form

Standard Coverage Determination: For a standard coverage determination about a Part D drug, which includes a request about payment for a Part D drug that you already received, generally, we must give you our determination no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. However, if your request involves a request for an exception (including a formulary exception, tiering exception or an exception from utilization management rules — such as dosage or quantity limits or step therapy requirements), we must give you our determination no later than 72 hours after we have received your physician’s supporting statement, which explains why the drug you are asking for is medically necessary. If you are requesting an exception, you should submit your prescribing physician’s supporting statement with the request, if possible.

We will give you a determination in writing about the prescription drug you have requested. If we do not approve your request, we must explain why and tell you of your right to appeal our determination. Appeal Level 1 explains how to file this appeal. If you have not received an answer from us within 72 hours after we have received your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

Fast Coverage Determination: For a fast coverage determination about a Part D drug that you have not received, we will give you our determination within 24 hours after you or your doctor ask for a fast review — sooner if your health requires. If your request involves a request for an exception, we will give you our determination no later than 24 hours after we have received your physician’s supporting statement, which explains why the non-formulary or non-preferred drug you are asking for is medically necessary.

We will give you a determination in writing about the prescription drug you have requested. If we do not approve your request, we must explain why and tell you of your right to appeal our determination. Appeal Level 1 explains how to file this appeal. If we decide you are eligible for a fast review, and you have not received an answer from us within 24 hours after receiving your request, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

If we do not grant your or your physician’s request for a fast review, we will give you our determination within the standard 72-hour timeframe discussed above. If we tell you about our determination not to provide a fast review by phone, we will send you a letter explaining our determination within three calendar days after we call you. The letter will also tell you how to file a grievance if you disagree with our determination to deny your request for a fast review and will explain that we will automatically give you a fast determination if you get a doctor’s support for a fast review.

If we make a coverage determination that is completely in your favor, what happens next depends on the situation.

Standard Coverage Determination: For a standard determination about a Part D drug, which includes a request about payment for a Part D drug that you already received, we must authorize or provide the benefit you have requested as quickly as your health requires, but no later than 72 hours after we received the request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 72 hours after we have received your physician’s supporting statement. If you are requesting reimbursement for a drug that you already paid for and received, we must send payment to you no later than 30 calendar days after we receive the request.

Fast Coverage Determination: For a fast determination about a Part D drug that you have not received, we must authorize or provide you with the benefit you have requested no later than 24 hours after receiving your request. If your request involves a request for an exception, we must authorize or provide the benefit no later than 24 hours after we have received your physician’s supporting statement.

If we deny your request, we will send you a written determination explaining the reason why your request was denied. We may decide completely or only partly against you. For example, if we deny your request for payment for a Part D drug that you have already received, we may say that we will pay nothing or only part of the amount you requested. If a coverage determination does not give you all that you requested, you have the right to appeal the determination.

To file a complaint electronically, please use the Medicare Complaint Form: English | Español.

The Medicare Beneficiary Ombudsman helps you with Medicare-related complaints, grievances, and information requests. To find out more about Medicare Ombudsman, click here: English | Español.

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a determination we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.

If you are unhappy or disagree with a coverage determination, you can ask for an appeal. You can generally appeal our determination not to cover a drug, vaccine or other Part D benefit. You can appeal our determination not to reimburse you for a Part D drug that you paid for. You can also appeal if you think we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription. Finally, if we deny your exception request, you can appeal.

Note: If we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment we require you to pay for the drug.

There are five levels to the appeals process. At each level, your request for Part D prescription drug benefits or payment is considered and a determination is made. The determination may be partly or completely in your favor (giving you some or all of what you have asked for), or it may be completely denied (turned down). If you are unhappy with the determination, there may be another step you can take to get further review of your request. Whether you are able to take the next step may depend on the dollar value of the requested drug or on other factors.

You make your request for coverage or payment of a Part D prescription drug directly to us. We review this request and make a coverage determination. If our coverage determination is to deny your request (in whole or in part), you can go on to the first level of appeal by asking us to review our coverage determination. If you are still dissatisfied with the outcome, you can ask for further review. If you ask for further review, your appeal is then sent outside of Elderplan where people who are not connected to us conduct the review and make the determination. After the first level of appeal, all subsequent levels of appeal will be decided by someone who is connected to the Medicare program or the federal court system. This will help ensure a fair, impartial determination.

If we deny all or part of your request in our coverage determination, you may ask us to reconsider our determination. This is called an “appeal” or “request for redetermination.”

Please call CVS/caremark 1-866-490-2102, if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our determination is not what you requested. When we receive your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look.

How you make your appeal depends on whether you are requesting reimbursement for a Part D drug you already received and paid for or authorization of a Part D benefit (that is, a Part D drug that you have not yet received). If your appeal concerns a determination we made about authorizing a Part D benefit that you have not received yet, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast coverage determination.

We must gather all the information we need to make a determination about your appeal. If we need your assistance in gathering this information, we will contact you. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.

You can give us your additional information in any of the following ways:

In writing, to: CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673.

The rules about who may file an appeal are almost the same as the rules about who may ask for a coverage determination. For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative or your prescribing physician.

You need to file your appeal within 60 calendar days from the date included on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline. To file a standard appeal, you can send the appeal to us in writing at:

CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673.

The rules about asking for a fast appeal are the same as the rules about asking for a fast coverage determination. You, your doctor or your appointed representative can ask us to give a fast appeal (rather than a standard appeal) by calling CVS/caremark 1-866-490-2102. Or, you can deliver a written request to:

CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673. Be sure to ask for a “fast,” “expedited,” or “72-hour” review.

Remember that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically treat you as eligible for a fast appeal.

How quickly we decide on your appeal depends on the type of appeal:

For a standard determination about a Part D drug, which includes a request for reimbursement for a Part D drug you already paid for and received, we have up to 7 calendar days to give you a determination after we receive your appeal. We will give you a determination more quickly if your health condition requires us to. If we do not give you our determination within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case.
For a fast determination about a Part D drug that you have not received, we have up to 72 hours to give you a determination after we receive your appeal. We will give you a quicker determination if your health requires us to. If we do not give you our determination within 72 hours, your request will automatically go to Appeal Level 2, where an independent organization will review your case.
What happens next if we decide completely in your favor?

For a determination about reimbursement for a Part D drug you already paid for and received, we must send payment to you no later than 30 calendar days after we receive your request to reconsider our coverage determination.
For a standard determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for as quickly as your health requires, but no later than 7 calendar days after we received your appeal.
For a fast determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 72 hours of receiving your appeal — or sooner, if your health would be affected by waiting this long.
What happens next if we deny your appeal?

If we deny any part of your appeal, you or your appointed representative have the right to ask an independent organization to review your case. This independent review organization contracts with the federal government and is not part of Elderplan.

If we deny any part of your first appeal, you may ask for a review by a government-contracted independent review organization. At the second level of appeal, your appeal is reviewed by an outside, independent review organization that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The independent review organization has no connection to us. You have the right to ask us for a copy of your case file that we sent to this organization.

You or your appointed representative must make a request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the determination on your first appeal. You must send your written request to the independent review organization whose name and address is included in the redetermination you receive from Elderplan.

If you want a fast appeal, the rules are the same as the rules about asking for a fast coverage determination, except your prescribing physician cannot file the request for you — only you or your appointed representative may file the request. Remember that if your prescribing physician provides a written or oral supporting statement explaining that you need the fast appeal, the independent review organization will automatically treat you as eligible for a fast appeal.

After the independent review organization receives your appeal, how long the organization can take to make a determination depends on the type of appeal:

For a standard request about a Part D drug, which includes a request about reimbursement for a Part D drug that you already paid for and received, the independent review organization has up to 7 calendar days from the date it received your request to give you a determination.
For a fast determination about a Part D drug that you have not received, the independent review organization has up to 72 hours from the time it receives the request to give you a determination.
If the independent review organization decides completely in your favor, the independent review organization will tell you in writing about its determination and the reasons for it. What happens next depends on the type of appeal:

For a determination about reimbursement for a Part D drug you already paid for and received, we must send payment to you within 30 calendar days from the date we receive notice reversing our coverage determination. We will also send the independent review organization a notice that we have abided by its determination.
For a standard determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we receive notice reversing our coverage determination. We will also send the independent review organization a notice that we have abided by its determination.
For a fast determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we receive notice reversing our coverage determination. We will also send the independent review organization a notice that we have abided by its determination.
If the review organization decides against you (either partly or completely), the independent review organization will tell you in writing about its determination and the reasons for it. You or your appointed representative may continue your appeal by asking for a review by an Administrative Law Judge (see Appeal Level 3), provided that the dollar value of the contested Part D benefit is more than the minimum requirement.

If the organization that reviews your case in Appeal Level 2 does not rule completely in your favor, you may ask for a review by an Administrative Law Judge.

As stated above, if the independent review organization does not rule completely in your favor, you or your appointed representative may ask for a review by an Administrative Law Judge. You must make a request for review by an Administrative Law Judge in writing within 60 calendar days after the date of the determination made at Appeal Level 2. You may request that the Administrative Law Judge extend this deadline for good cause. You must send your written request to:

CVS/caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

Or you may fax it to: 1-855-633-7673.

We will forward your request to the Administrative Law Judge on your behalf. During the Administrative Law Judge review, you may present evidence, review the records (by either receiving a copy of the file or accessing the file in person when feasible) and be represented by counsel. The Administrative Law Judge will not review your appeal if the dollar value of the requested Part D benefit is less than the required minimum. If the dollar value is less than the required minimum, you may not appeal any further.

If we have refused to provide Part D prescription drug benefits, the dollar value for requesting an Administrative Law Judge hearing is based on the projected value of those benefits. The projected value includes any costs you could incur based on the number of refills prescribed for the requested drug during the plan year. Projected value includes your co-payments, all expenditures incurred after your expenditures exceed the initial coverage limit and expenditures paid by other entities.

You may also combine multiple Part D claims to meet the dollar value if:

The claims involve the delivery of Part D prescription drugs to you;
All of the claims have received a determination by the independent review organization as described in Appeal Level 2;
Each of the combined requests for review are filed in writing within 60 calendar days after the date that each determination was made at Appeal Level 2; and
Your hearing request identifies all of the claims to be heard by the Administrative Law Judge.
How soon does the Administrative Law Judge make a determination? The Administrative Law Judge will hear your case, weigh all of the evidence up to this point and make a determination as soon as possible.

If the Administrative Law Judge decides in your favor, he or she will tell you in writing about his or her determination and the reasons for it. What happens next depends on the type of appeal:

For a determination about payment for a Part D drug you already received, we must send payment to you no later than 30 calendar days from the date we receive notice reversing our coverage determination.
For a standard determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we receive notice reversing our coverage determination.
For a fast determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we receive notice reversing our coverage determination.
If the Administrative Law Judge rules against you, you have the right to appeal this determination by asking for a review by the Medicare Appeals Council (Appeal Level 4). The letter you get from the Administrative Law Judge will tell you how to request this review.

The Medicare Appeals Council will first decide whether to review your case. There is no minimum dollar value for the Medicare Appeals Council to hear your case. If you got a denial at Appeal Level 3, you or your appointed representative can request review by filing a written request with the Council.

The Medicare Appeals Council does not review every case it receives. When it gets your case, it will first decide whether or not to review your case. If they decide not to review your case, then you may request a review by a Federal Court Judge (see Appeal Level 5). The Medicare Appeals Council will issue a written notice advising you of any action taken with respect to your request for review. The notice will tell you how to request a review by a Federal Court Judge.

How soon will the Council make a determination? If the Medicare Appeals Council reviews your case, it will make its determination as soon as possible. If the Council decides in your favor, the Medicare Appeals Council will tell you in writing about its determination and the reasons for it. What happens next depends on the type of appeal:

For a determination about payment for a Part D drug you already received, we must send payment to you no later than 30 calendar days from the date we receive notice reversing our coverage determination.
For a standard determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we receive notice reversing our coverage determination.
For a fast determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we receive notice reversing our coverage determination.
If the Council decides against you and the amount involved is more than the required minimum, you have the right to continue your appeal by asking a Federal Court Judge to review the case (Appeal Level 5). The letter you get from the Medicare Appeals Council will tell you how to request this review. If the value is less than the required minimum, the Council’s determination is final, and you may not take the appeal any further.

In order to request judicial review of your case, you must file a civil action in a United States district court. The letter you get from the Medicare Appeals Council in Appeal Level 4 will tell you how to request this review. The Federal Court Judge will first decide whether or not to review your case. If the contested amount is more than the required minimum, you may ask a Federal Court Judge to review the case.

How soon will the Federal Court Judge make a determination? The Federal judiciary is in control of the timing of any determination.

If the Federal Court Judge decides in your favor, we will receive notice of a judicial determination. What happens next depends on the type of appeal:

For a determination about payment for a Part D drug you already received, we must send payment to you within 30 calendar days from the date we receive notice reversing our coverage determination.
For a standard determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 72 hours from the date we receive notice reversing our coverage determination.
For a fast determination about a Part D drug you have not received, we must authorize or provide you with the Part D drug you have asked for within 24 hours from the date we receive notice reversing our coverage determination.
If the Federal Court Judge decides against you, the Judge’s determination is final and you may not take the appeal any further.