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:

  • 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)

May 2018:  The standardized notice Medicare Prescription Drug Coverage and Your Rights (CMS-10147) ("pharmacy notice") and form instructions have been approved by the Office of Management and Budget (OMB).  Plans should take note of the expiration date in the revised form and accompanying instructions.

All plans should begin using the revised pharmacy notice as soon as possible, but no later than July 1, 2018.

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

January 2019: The Notice of Denial of Medicare Part D Prescription Drug Coverage, both in English and Spanish, has been updated to include information related to timeframes for issuing decisions on payment redeterminations.

To download the denial notice and its corresponding instructions, please click on the links in the "Downloads" section below.

Questions regarding the Part D denial notice can be submitted through this link: https://appeals.lmi.org/

Model Notices

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.

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.

February 2019: Model notices have been updated with minor changes (e.g., formatting or restructuring for clarity), to align with the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, released February 2019.

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
  • Notice of Redetermination
  • Notice of Case Status
  • Notice of Formulary or Cost-sharing Change
  • Request for Additional Information
  • Notice of Inquiry 

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).

Page Last Modified:
10/31/2019 12:55 PM