PART D Appeal Process

ONECare
Step One: Decision Steps
Requestor Not
Initial Decision rendered on
Satisfied with
Requestor submits a request for Coverage,
Decision
Coverage, Benefit, or Payment Benefit, or Step Two: Independent
Payment Appeal Level One: Review Steps
Appeal Process Initiated and
ONECare Completes an
Requestor Investigation of Initial Decision Appeal Decision
Appeals may be Rendered
Exception Request: Exception that Upholds the
A Requestor not satisfied with Decision Initial Decision
a Decision based on
ONECare’s Drug Formulary
may Request an exception for
a drug not on ONECare’s
Appeal Decision may be If Requestor
Formulary Rendered that Fully or
Exception is Not Satisfied, may
Denied Partially Overturns the Submit Next Level
Initial Decision Appeal

Step Three:
Exception Appeal Level Two:
Approved
Independent Review
PROCESS Entity (IRE)
STOPPED No Remaining
Appeal Levels
Requestor
DECISION IS Satisfied
FINAL
APPEAL
PROCESS
STOPPED If Requestor
Step Six:
Not Satisfied, may
Appeal Level Five:
Submit Next Level
Federal Court Appeal
Review of Payment

If Requestor Step Five: If Requestor Step Four:

Not Satisfied, Appeal Level Four: Not Satisfied, Appeal Level Three:
may Submit Medicare Appeals may Submit Administrative Law
Next Level Council Review (MAC) Next Level Judge Review (ALJ)
Appeal Appeal