Plan Sponsor Notices and Other Documents

This page includes a number of notices and other documents for plan sponsors.

Standardized Notices

CMS has developed the following standardized notices to be used by plan sponsors:

• Notice of Denial of Medicare Prescription Drug Coverage
• Medicare Prescription Drug Coverage and Your Rights

To view the standardized notices, click on the links in the "Downloads" and "Related Links" sections below.

Model Notices

The following model notices are contained in the appendices to Chapter 18 of the Prescription Drug Benefit Manual:

• Appendix 3 - Notice of Right to an Expedited Grievance
• Appendix 4 - Notice of Redetermination
• Appendix 6 - Notice of Case Status
• Appendix 7 - Notice of Plan's Decision to Extend the Deadline for Making a Decision Regarding a Grievance
• Appendix 8 - Notice of Plan's Decision Regarding a Grievance
• Appendix 9 - Notice of Effectuation to Part D Independent Review Organization
• Appendix 10 - Notice of Formulary or Cost-sharing Change
• Appendix 11 - Request for Additional Information
• Appendix 12 - Notice of Inquiry Regarding an Excluded Drug
• Appendix 13 - Request for Reconsideration

To access the model notices, click on the "Model Notices" link in the "Downloads" section below. Each model notice is available in both Microsoft Word and PDF formats.

CMS has published additional guidance through the Health Plan Management System (HPMS) that clarifies a number of issues related to Part D grievances, coverage determinations, and appeals.  To view all the guidance released through HPMS, click on the related link in the "Related Links" section below.