Medicare Advantage and Prescription Drug Appeals
Medicare Advantage plans (Part C) and prescription drug plans (Part D) follow distinct appeals paths with specialized procedures and deadlines.
Medicare Advantage Part C Reconsideration
If your Medicare Advantage plan denies coverage or payment, file a Level 1 appeal with the plan within 65 calendar days of the denial notice.
If the plan upholds its denial, it must automatically forward your claim to an independent review entity for Level 2 review.
Effective May 1, 2026, C2C Innovative Solutions, Inc. officially replaced MAXIMUS as the Part C Independent Review Entity handling Level 2 appeals.
Fast-Track Prior Authorization Timeframes
Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), effective January 1, 2026, Medicare Advantage plans face stricter authorization deadlines.
Plans must decide standard prior authorization requests within seven calendar days, cutting the previous 14-day window in half to prevent treatment delays.
For urgent medical needs where delays threaten health, plans must decide within 72 hours and provide specific clinical denial rationales to support appeals.
Appealing Prescription Drug Denials Under Part D
Part D appeals address denied medications, quantity limits, or tier placements. If a pharmacy rejects a prescription, request a formal coverage determination from your plan.
Reviewing where your medications fall in relation to the Part D out-of-pocket cap can help clarify whether pursuing a tier exception will provide meaningful financial relief.
You can request a formulary exception if a non-covered drug is clinically necessary. Your doctor must explain why formulary alternatives are ineffective or unsafe.
The plan must decide standard exception requests within 72 hours of receiving your doctor’s statement, or within 24 hours for urgent cases.
Fast Discharge Appeals Through QIOs
If a provider terminates covered care prematurely, you have fast appeal rights that bypass standard plan reviews.
Contact your regional Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Calling by the notice deadline pauses discharge while independent doctors review your care.
