Crosswalk Coverage Pharmacy Notice 04 30 08

Crosswalk Document for Changes to CMS-10147

Medicare Prescription Drug Coverage and Your Rights

Submitted for Collection May 2008

Summary of Changes to CMS-10147:

The notice “Medicare Prescription Drug Coverage and Your Rights” is used by Part D plans’ network pharmacies to inform Part D enrollees of the right to contact their drug plan to ask for a coverage determination, including an exception request, when the enrollee disagrees with information provided by the pharmacist (e.g., the prescription cannot be filled as written). Based on experience since inception of the Part D program in January 2006, CMS believes that this standardized notice should be revised to include certain nonsubstantive changes for purposes of providing a clearer notice to Part D program enrollees about their rights. These changes do not affect the burden associated with distribution or posting of the notice.

The following nonsubstantive changes have been made to the notice:

• In each instance where “physician” or “doctor” was used, the notice now uses “prescriber” to account for instances where an enrollee’s prescription is written by a non-physician provider with prescribing authority under State law, such as a nurse practitioner or physician’s assistant.

• In the introductory sentence, the notice more clearly states that the enrollee has the right to request a coverage determination (in addition to the right to get a written explanation of why a drug isn’t covered).

• The notice more clearly explains that an exception is a special type of coverage determination and that an exception may also be requested if the enrollee believes that a plan coverage rule, such as a quantity limit, should not apply for reasons of medical necessity.

• In the third bullet point/item #1 under the section “What you need to do” the enrollee is instructed to provide information on the dose and strength of the prescribed drug, if known.

• The paragraph that explains that the drug plan will provide a written explanation giving the specific reasons why the drug is not covered and explain how to request an appeal has been moved to the end of the notice. We believe this text is more appropriately placed following the “What you need to do” section.

No changes to the instructions are necessary.