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

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)

October 2017: The Spanish translation of The Notice of Denial of Medicare Part D Prescription Drug Coverage has been updated.  A corrected version can be found in the “Downloads” section.

July 2017:  The Notice of Denial of Medicare Part D Prescription Drug Coverage, Form CMS-10146, 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 instructions.

Significant revisions to the notice and instructions include:

  • A suggestion that the enrollee share a copy of the decision with his or her prescriber so that next steps can be discussed. The notice also explains that a copy of the decision was sent to the prescriber if that prescriber made the request on the enrollee’s behalf;
  • Additional language (as applicable) for MA-PDs and standalone Part D plans that must be inserted for denied prescription drugs that may be covered under Medicare Part A or B;
  • Language providing information on how enrollees can request the notice in an alternative format; and
  • The national toll-free number for the State Health Insurance Program National Technical Assistance Center (SHIP TA Center).

All plans should begin using the denial notice as soon as possible, but no later than October 1, 2017.

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 emailed to: PartD_Appeals@cms.hhs.gov

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.

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 Plan's Decision to Extend the Deadline for Making a Decision Regarding a Grievance
  • Notice of Plan's Decision Regarding a Grievance
  • Notice of Effectuation to Part D Independent Review Organization
  • 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).

Related Links

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