Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage

Approved OMB #0938-0976

[Logo]
Notice of Denial of Medicare Prescription Drug Coverage
Date:
Enrollee’s name:

Member number:

We have denied coverage or payment for the following prescription drug or drugs that you or
your prescriber requested:

We denied this request because:

What If I Don’t Agree With This Decision?

You have the right to appeal. If you want to appeal, you must request your appeal within 60
calendar days after the date of this notice. We can give you more time if you have a good reason
for missing the deadline. You have the right to ask us for a formulary exception if you believe
you need a drug that is not on our list of covered drugs (formulary). You have the right to ask us
for a coverage rule exception if you believe a rule such as prior authorization or a quantity limit
should not apply to you. You can ask for a tiering exception if you believe you should get a
drug at a lower cost-sharing amount. Your prescriber must provide a statement to support your
exception request.
Who May Request an Appeal?
You, your prescriber, or your representative may request an expedited (fast) or standard appeal.
You can name a relative, friend, advocate, attorney, doctor, or someone else to be your
representative. Others may already be authorized under State law to be your representative.
You can call us at:
to learn how to appoint a representative. If
you have a hearing or speech impairment, please call us at TTY:
.

Form No. CMS-10146

Important Information About Your Appeal Rights

There Are Two Kinds of Appeals
You Can Request
Expedited (72 hours) - You, your prescriber,
or your representative can request an
expedited (fast) appeal if you or your
prescriber believe that your health could be
seriously harmed by waiting up to 7 days for
a decision. You cannot request an expedited
appeal if you are asking us to pay you back
for a prescription drug you already received.
If your request to expedite is granted, we
must give you a decision no later than 72
hours after we get your appeal.
If your prescriber asks for an
expedited appeal for you, or supports
you in asking for one, and indicates that
waiting for 7 days could seriously harm
your health, we will automatically
expedite your appeal.
If you ask for an expedited appeal
without support from your prescriber, we
will decide if your health requires an
expedited appeal. We will notify you if
we do not give you an expedited appeal
and we will decide your appeal within 7
days.
Standard (7 days) – You, your prescriber, or
your representative can request a standard
appeal. We must give you a decision no later
than 7 days after we get your appeal.
What Do I Include with My Appeal
Request?
You should include your name, address,
Member number, the reasons for appealing,
and any evidence you wish to attach. If your
appeal relates to a decision by us to deny a
drug that is not on our formulary, your
prescriber must indicate that all the drugs on
any tier of our formulary would not be as
effective to treat your condition as the
requested off-formulary drug or would harm
your health.

How Do I Request an Appeal?
For an Expedited Appeal: You, your
prescriber, or your representative should
contact us by telephone or fax at the
numbers below:
Phone:
Fax:
For a Standard Appeal: You, your
prescriber, or your representative should mail
or deliver your written appeal request to the
address below:

What Happens Next? If you appeal, we will
review your case and give you a decision. If
any of the prescription drugs you requested
are still denied, you can request an
independent review of your case by a
reviewer outside of your Medicare Drug Plan.
If you disagree with that decision, you will
have the right to further appeal. You will be
notified of your appeal rights if this happens.
Contact Information:
If you need information or help, call us at:
Toll Free:
TTY:
Other Resources To Help You:
Medicare Rights Center
Toll Free: 1-888-HMO-9050
Elder Care Locator
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048