The 72-Hour Rule in Medicare: Part D Coverage Determinations
When people say "the 72-hour rule" in a Medicare drug context, they usually mean the standard Part D coverage determination deadline: a plan must decide a drug coverage request within 72 hours of receipt (42 CFR § 423.568). For expedited requests — where the standard timeframe could seriously jeopardize the enrollee's health — the deadline is 24 hours (§ 423.570).
Do not confuse this with CMS-0057-F
The Interoperability and Prior Authorization Final Rule (CMS-0057-F) sets 72-hour urgent / 7-calendar-day standard timeframes for prior authorization of medical items and services — and explicitly excludes drugs. The two regimes are commonly conflated:
| Regime | Scope | Urgent/expedited | Standard |
|---|---|---|---|
| Part D coverage determination (§§ 423.568/423.570) | Prescription drugs | 24 hours | 72 hours |
| CMS-0057-F prior authorization | Medical items/services (drugs excluded) | 72 hours | 7 calendar days |
Full detail on the medical-side rule: CMS-0057-F turnaround times.
Operational notes for plans
- The clock starts when the plan receives the request; missing prescriber support does not stop it.
- Exceptions (formulary, tiering) follow the same timeframes.
- Auto-adverse determinations on missed deadlines are appealable and visible to CMS — chronic misses are a Star Ratings and audit issue.
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