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11/1/21, 2:05 PM Exceptions | CMS
other entity, or on any other written document (e.g., a letter) prepared by
the prescriber.

February 2019: The Request for a Medicare Prescription Drug Coverage
Determination Model Form has been updated.

How a Plan Sponsor Processes an Exception Request
For requests for benefits, once a plan sponsor receives a prescriber's
supporting statement, it must provide written notice of its decision within 24
hours for expedited requests or 72 hours for standard requests. The initial
notice may be provided verbally so long as a written follow-up notice is
mailed to the enrollee within 3 calendar days of the verbal notification.

For requests for payment that involve exceptions, a plan sponsor must
provide notice of its decision (and make payment when appropriate) within
14 calendar days after receiving a request.

If the plan sponsor's coverage determination is unfavorable, the decision
will contain the information needed to file a request for redetermination with
the plan sponsor.

A list of specific contacts at Part D sponsors can be found at:
/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/PartDContacts

For more information about exceptions, see section 40.5 in the Parts C & D
Enrollee Grievances, Organization/Coverage Determinations, and Appeals
Guidance in the "Downloads" section below.

Downloads

Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance (PDF)
Model Coverage Determination Req Form and Instructions (ZIP)