This page includes a number of notices and other documents for plan sponsors. Questions regarding any of the Part D notices can be submitted through this link: https://appeals.lmi.org/

Standardized Notices

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

• Medicare Prescription Drug Coverage and Your Rights ("Pharmacy Notice")
• Notice of Denial of Medicare Part D Prescription Drug Coverage

Medicare Prescription Drug Coverage and Your Rights (CMS-10147)

The standardized notice Medicare Prescription Drug Coverage and Your Rights (CMS-10147) ("pharmacy notice") and form instructions are available in the "Downloads" section below.).  

Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146)

The Notice of Denial of Medicare Part D Prescription Drug Coverage, both in English and Spanish, which includes information related to Part B step therapy requirements, and its corresponding instructions, is available in the "Downloads" section below.

Model Notices

CMS model notices contain all of the elements CMS requires for proper notification to enrollees or prescribers, if applicable. Plan sponsors may modify the model notices and submit them to the appropriate CMS regional office for review and approval. Plan sponsors may use these notices at their discretion.

January 2021:  Beginning February 1, 2021, C2C Solutions, Inc is the Part D IRE. A Model Redetermination Notice which includes the new Part D QIC (C2C) information has been provided in the "Downloads" section. 

February 2021:  For drug management program (DMP) appeals plan sponsors may use the DMP Model Redetermination Notice when it has upheld its at-risk determination and is required to send the case file to the IRE for review.  The new model notice can be found in the “Downloads” section.

NOTE REGARDING MEDICARE NOTICES WITH QIO INFORMATION:

Providers, suppliers, Medicare Advantage Organizations and Prescription Drug Plans should make certain that their Medicare notices include the correct Quality Improvement Organization (QIO) contact information.  Please see  www.qioprogram.org  for QIO details.

The following model notices are available in both Microsoft Word and PDF formats in the "Downloads" section below:

• Notice of Right to an Expedited Grievance
• Model Redetermination Notice
• Notice of Case Status
• Notice of Formulary or Cost-sharing Change
• Request for Additional Information
• Notice of Inquiry 
• DMP Model Redetermination Notice
• Notice of Dismissal of Coverage Request 
• Notice of Dismissal of Appeal Request

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 (see "HPMS Guidance History" in the "Related Links" section below).