Standardized Notices

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

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

Medicare Drug Coverage and Your Rights (CMS-10147)

The standardized notice Medicare 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, which includes the 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.

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 at the bottom of this page.

• Notice of Right to an Expedited Grievance
• Notice of Case Status
• Request for Additional Information
• Notice of Inquiry 
• DMP Model Redetermination Notice
• Denial of Medicare Drug Coverage
• Medicare Drug Coverage Denial Request for Redetermination
• Notice of Dismissal of Coverage Request
• Notice of Dismissal of Appeal Request
• Model Redetermination Notice 

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).