The six appeal levels

Decided by: Your Part D plan sponsor.

No deadline to make this first request — it's your initial ask, not yet an appeal. The 65-day appeal clock only starts once the plan denies it.rule42 CFR 423.566

72 hours for a standard drug-benefit request (24 hours if expedited). For an exception request, the clock instead runs from receipt of your prescriber's supporting statement — 72 hours standard / 24 hours expedited from that point, or from the end of a 14-day wait if the plan never receives one. Payment requests: 14 calendar days (42 CFR § 423.568, § 423.570, § 423.572).

Where to send it: Your Part D plan sponsor — the phone number is on your plan membership card; forms can also be submitted through the plan's website.

Decided by: Your Part D plan sponsor (a different reviewer than the one who made the original denial).

65 days from the date on the denial notice. The rule (42 CFR § 423.582) gives you 60 days from when you receive the denial, and receipt is presumed to be 5 days after the notice's own date unless shown otherwise — 60 + 5 = 65 days from the notice date.rule42 CFR 423.582

The plan must decide within 7 calendar days for a standard request about a drug you haven't received yet, 14 calendar days for a request about payment for a drug already purchased, or 72 hours if expedited (42 CFR § 423.590, § 423.584).

If the plan fails to meet its own deadline, that failure itself counts as an adverse redetermination, and the plan must forward your case to the Independent Review Entity (C2C) within 24 hours — you don't have to do anything to trigger this (42 CFR § 423.590(c)/(e)).

Where to send it: Your Part D plan sponsor — the address/fax is printed on the denial notice itself (42 CFR § 423.582).

Decided by: An independent outside entity under contract with CMS — C2C Innovative Solutions — not the plan (42 CFR § 423.600).

65 days from the date on the plan's redetermination notice (60 days plus the same 5-day mailing presumption as Level 1).rule42 CFR 423.600

The IRE must decide within the same timeframes as Level 1 — 7 calendar days standard / 14 calendar days for payment / 72 hours if expedited (42 CFR § 423.600(d), which incorporates § 423.590's own timeframes).

If the IRE's decision doesn't fully reverse the denial, its notice must explain your right to an Administrative Law Judge (ALJ) hearing and how to request one (42 CFR § 423.602).

Where to send it: Nothing to send at this level unless you're filing the appeal yourself — the plan forwards your case file to C2C directly. You may submit additional evidence to C2C yourself.

Decided by: An Administrative Law Judge or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA).

65 days from receiving the IRE's decision notice (42 CFR § 423.2002).rule42 CFR 423.2002

An ALJ or attorney adjudicator must issue a decision within 90 calendar days of a standard request, or 10 calendar days if a request for an expedited hearing is granted (42 CFR § 423.2016). Unlike Medicare Advantage, Part D's own rule DOES set a fixed decision deadline at this level.

The dollar amount still in dispute must meet a yearly minimum set by the Secretary — $200 for 2026, the same combined threshold Medicare publishes annually for Parts A, B, C, and D appeals together (42 CFR § 423.2006).

None — you must actively request a hearing; it does not happen automatically.

Where to send it: The entity named in the IRE's own reconsideration notice (42 CFR § 423.2014).

Decided by: The Medicare Appeals Council, part of HHS's Departmental Appeals Board.

60 days from the ALJ's or attorney adjudicator's decision (42 CFR § 423.2102).rule42 CFR 423.2102

The Council reviews the ALJ's record; no fixed decision deadline is stated in the corpus for this level.

None — you must actively request Council review.

Where to send it: The Departmental Appeals Board, following the instructions printed in the ALJ's decision (42 CFR § 423.2106).

Decided by: A judge in a United States district court.

65 days from the Council's decision — 60 days under § 423.2130 itself, plus the same 5-day mailing presumption CMS Guidance §70.3 extends to this level (the section's own text doesn't restate it, matching a real gap the Medicare Advantage pack's own Level 5 already documents for its own parallel section).rule42 CFR 423.2130

Set by the court, the same as any federal civil case.

The dollar amount still in dispute must meet a yearly minimum — $1,960 for 2026, the same combined Parts A/B/C/D threshold (42 CFR § 423.2006).

Where to send it: The United States District Court for the judicial district where you reside (or the District Court for the District of Columbia if you don't reside in any judicial district) (42 CFR § 423.2136).