Medicare Prescription Drug Appeals and Grievances

A grievance is an expression of dissatisfaction (other than a coverage determination) with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested.

Examples of grievances include:

• Problems with customer service;
• If an enrollee disagrees with a plan sponsor's decision not to expedite a request for a coverage determination or redetermination; or
• If an enrollee believes the plan sponsor's notices and other written materials are difficult to understand.

An enrollee or an enrollee's representative may file a grievance orally or in writing with the plan sponsor.  Grievances must be filed with the plan sponsor no later than 60 days after the event or incident that brought about the grievance.

The plan must provide meaningful procedures for timely hearing and resolution of both standard and expedited grievances between enrollees and the plan sponsor or any other entity or individual through whom the plan sponsor provides covered benefits under any Part D plan it offers.  Plans must notify all concerned parties upon completion of the investigation as expeditiously as the enrollee's health condition requires, but no later than 30 days after the grievance is received, unless in the best interest of the enrollee the timeframe is extended by the plan sponsor for up to 14 calendar days. 

However, the plan must respond to a grievance within 24 hours if:

1. The grievance involves a refusal by the Part D plan sponsor to grant an enrollee's request for an expedited coverage determination or expedited redetermination, and
2. The enrollee has not yet purchased or received the drug that is in dispute.

For more information about the grievance process and appointing a representative, see section 30 and 20 (respectively) of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in the “Downloads” section below. A copy of the model notice plans may use to notify enrollees about their right to an expedited grievance can be found at “Plan Sponsor Notices and Other Documents” using the left navigation menu on this page.