Disclaimer Policy

Form Instructions
Medicare Prescription Drug Coverage and Your Rights
Standardized Pharmacy Notice (CMS-10147)

Each Medicare Part D plan sponsor must arrange with its network pharmacies for the distribution of this notice to Part D enrollees when a prescription cannot be covered (“filled”) under the Medicare Part D benefit at the point of sale (POS). The notice must be provided to the enrollee if the pharmacy receives a transaction response (rejected or paid) indicating the claim is not covered by Part D. The notice instructs enrollees about their right to contact their Part D plan to request a coverage determination, including an exception. This notice fulfills the requirements at 42 CFR §423.562(a) (3) and §423.128(b) (7) (iii).

This is a standardized notice, the content of which may not be altered. The notice must be provided in 12 point font. The OMB control number must be displayed in the upper right corner of the notice. The fields for the enrollee’s name and the drug and prescription number are optional and may be populated by the pharmacy.

Heading

Logo not required. Pharmacies may place their logo in the space above the optional fields for the enrollee’s name and the drug and prescription number.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0975. The time required to complete this information collection is estimated to average one (1) minute per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OMB Approval No. 0938- 0975

Enrollee ’s Name: (Optional)

Drug and Prescription Number: (Optional)

Medicare Prescription Drug Coverage and Your Rights

Your Medicare rights
You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” if you believe:

  • You need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;”
  • A coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or
  • You need to take a non-preferred drug and you want the plan to cover the drug at the preferred drug price.

What you need to do
You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll -free phone number on the back of your plan membership card, or by going to your plan’s website. You or your prescriber can request an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:

  1. The name of the prescription drug that was not filled. Include the dose and strength, if known.
  2. The name of the pharmacy that attempted to fill your prescription.
  3. The date you attempted to fill your prescription.
  4. If you ask for an exception, your prescriber will need to provide your drug plan with a statement explaining why you need the off-formulary or non- preferred drug or why a coverage rule should not apply to you.

Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision.

Refer to your plan materials or call 1-800-Medicare for more information.

Form CMS -10147