Questions & answers · Health insurance
How long does a Medicare Part D plan have to decide a prescription coverage request?
Health insuranceAppealChecked Nov 5, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: 42 CFR 423.568 (eCFR (current as of 2026-11-02)) · § 423.568(b)-(c) View original ↗
In short
- A Part D plan has 72 hours to decide a standard drug request.
- A fast request gets 24 hours.
- A payment request gets 14 days.
What this means
A Part D plan must decide a standard drug request no later than 72 hours after it gets it [1]. If you ask the plan to pay you back for a drug, it has no later than 14 calendar days [1]. You can ask for a fast decision. If the plan agrees, it must decide within 24 hours after it gets the request [2]. A fast decision can't be used to pay you back for drugs you already got [4]. You can also ask for an exception, such as a formulary or tier exception. Then the plan has no later than 72 hours after it gets your prescriber's statement [3].
Where this comes from (4)
[1] 42 CFR 423.568 (eCFR (current as of 2026-11-02)) · § 423.568(b)-(c) · checked 2026-11-05
When a party makes a request for a drug benefit, the Part D plan sponsor must notify the enrollee … no later than 72 hours after receipt of the request. … (c) Timeframe for requests for payment. … no later than 14 calendar days after receipt of the request.
[2] 42 CFR 423.572 (eCFR (current as of 2026-11-02)) · § 423.572(a) · checked 2026-11-05
a Part D plan sponsor that approves a request for expedited determination must make its determination and notify the enrollee … no later than 24 hours after receiving the request.
[3] 42 CFR 423.568 (eCFR (current as of 2026-11-02)) · § 423.568(b) · checked 2026-11-05
For an exceptions request, the Part D plan sponsor must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its determination as expeditiously as the enrollee's health condition requires, but no later than 72 hours after receipt of the physician's or other prescriber's supporting statement.
[4] 42 CFR 423.570 (eCFR (current as of 2026-11-02)) · § 423.570(a) · checked 2026-11-05
An enrollee or an enrollee's prescribing physician or other prescriber may request that a Part D plan sponsor expedite a coverage determination … This does not include requests for payment of Part D drugs already furnished.
How we found this
We matched your question to 4 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
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Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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