The Part D coverage-determination clock, in hours
Checked against the current rules on September 23, 2026.
Unlike a Medicare Advantage reconsideration, a Part D coverage determination (the enrollee's first ask) is timed in hours, not days — and an exception request's own clock doesn't start when you'd expect.
Source: 42 CFR Part 423, Subparts M & U — Part D Grievances, Coverage Determinations, Redeterminations, Reconsiderations, ALJ Hearings, Council Review, and Judicial Review.
For a standard drug-benefit request, the plan must notify the enrollee of its determination no later than 72 hours after receipt of the request.42 CFR 423.568
For an exceptions request specifically, that 72-hour clock runs from receipt of the prescriber's own supporting statement — not from the original request — or, if no statement arrives, from the end of a 14-calendar-day wait.42 CFR 423.568
An enrollee or prescriber can ask the plan to expedite a coverage determination; the plan must grant an expedited (24-hour) timeframe once the prescriber indicates that waiting the standard timeframe could seriously jeopardize the enrollee's life, health, or ability to regain maximum function.42 CFR 423.570
What this means for your appeal
If the plan's own written denial arrives well past 72 hours from when your prescriber's statement was actually received, that timing itself is worth raising — a late decision doesn't erase the plan's own obligation, and its own failure to meet the timeframe counts as an adverse determination that must be forwarded onward automatically.42 CFR 423.568
Because the clock runs from receipt of the prescriber's statement rather than the original request, it's worth asking the pharmacy or plan for the exact date-and-time stamp they show for that statement's arrival — families sometimes calendar the deadline from the date they themselves called the plan, which can be days earlier or later than the date the plan's own records show the statement actually landed.
An hour-scale clock also means a written notice mailed to a family can lag behind the plan's own internal decision by a day or two; if the notice's own postmark or delivery date is well past when the decision was supposedly made, that gap is itself worth documenting, since it can matter for calculating downstream deadlines that key off the date of the decision rather than the date the family actually received it.
Sources — last checked September 23, 2026
- 42 CFR 423.568as of September 23, 2026
- 42 CFR 423.570as of September 23, 2026
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
