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

Form Instructions

“Medicare Prescription Drug Coverage and Your Rights”

Pharmacy Notice

CMS-10147

A Medicare Part D plan must provide this notice to its network pharmacies for use in instructing enrollees to contact their Part D plan (Medicare drug plan) to obtain a coverage determination, including a formulary or tiering exception, if the enrollee disagrees with the information provided by the pharmacist. This notice may be distributed to enrollees or conspicuously posted at the pharmacy. Posted notices must be large enough to be easily read by the target audience. This notice fulfills the requirements at 42 CFR §423.562(a)(3).

This is a standard notice. Part D plans may not deviate from the content of this notice. Please note that the OMB control number must be displayed in the upper right corner of the notice.

Heading

Logo not required. Pharmacies may elect to place their logo in the space above “Medicare Prescription Drug Coverage and Your Rights.”

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0975. The time required to complete this information collection is estimated to average one minute per response, including the time to select the preprinted form and hand it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.