Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

Form Instructions for the

“Notice of Denial of Medicare Prescription Drug Coverage”

CMS-10146

A Part D plan must complete and issue this notice whenever it denies a Part D plan enrollee’s request for prescription drugs. This is not model language. This is a standard form. Part D plans may not deviate from the content of the form provided. Please note that the OMB number must be displayed in the upper right corner of the notice.

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Logo—A logo is not required. Part D plans may elect to place their logo in this space. The name, address, and telephone number of the Part D plan must be immediately under the logo, if not incorporated within the logo.

Date—Enter the month, day, and year that the notice is issued to the enrollee or the enrollee’s appointed representative.

Enrollee’s Name—Enter the enrollee’s full name.

Member’s ID Number—Enter the enrollee’s drug plan member ID number. This number should not include or be the enrollee’s Social Security Number or Health Insurance Claim (HIC) number.

We have denied coverage of the following prescription drug(s) that you or your prescriber physician requested—List the denied prescription drug(s) that were requested by the enrollee or prescriberphysician.

We denied this request because—The Part D plan must provide a specific and detailed explanation of why the prescription drug is being denied, including a description of any applicable Medicare coverage rule or any other applicable Part D plan policy upon which the denial decision was based. The plan’s explanation must be written in a manner calculated to be understood by the enrollee.

Section Titled: What If I Don’t Agree With This Decision?

No information is required to be completed.

Section Titled: Who May Request an Appeal?

In the spaces provided, the Part D plan is required to enter the Part D plan’s telephone and TTY/TDD numbers that enrollees should use to obtain information or forms on how to name an appointed representative.

Section Titled: There Are Two Kinds of Appeals You Can Request

No information is required to be completed.

Section Titled: What Do I Include with My Appeal?

No information is required to be completed.

Section Titled: How Do I Request an Appeal?

Under the subsection “For a Standard Appeal” –The Part D plan must provide the address(es) where the enrollee or the enrollee’s appointed representative can mail or hand deliver a standard appeal request. If the Part D plan permits enrollees to make oral appeal requests, then it must provide the telephone and TTY numbers that the enrollee or the enrollee’s appointed representative may use to request a standard appeal.

Under the subsection “For an Expedited Appeal” –The Part D plan is required to enter the telephone, TTY or fax number that the enrollee, the enrollee’s prescriber, or the enrollee’s appointed representative can use to request an expedited (fast) appeal.

Section Titled: What Happens Next?

No information is required to be completed.

Section Titled: Contact Information

In the spaces provided, the Part D plan is required to enter the Part D plan’s

telephone and TTY/TDD numbers that the enrollee or the enrollee’s

appointed representative can call if they need information or help.

Section Titled: Other Resources to Help You

No information is required to be completed.

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 collection is 0938-0976NEW. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.