CMS-10147.Crosswalk Document

Crosswalk Document for Changes to CMS-10147
Medicare Prescription Drug Coverage and Your Rights
Submitted for 30 day comment period August 2011

Summary of Changes to CMS-10147:
Beginning January 1, 2012, Part D plan network pharmacies will provide a written copy
of the standardized pharmacy notice to enrollees (beneficiaries) when an enrollee’s
prescription cannot be filled under the Medicare Part D benefit and the rejection cannot
be resolved at point of sale.
The following changes have been made to the form based on regulatory changes:
The content of the standardized pharmacy notice was revised to refer the enrollee
to the Part D plan’s toll-free phone number on the back of the plan member card
and to the plan’s website to request a coverage determination. This change was
made to comport with new rules as set out in CMS-4144-F, published in the
Federal Register April 15, 2011.

The following changes have been made to the notice due to comments received during
the 60 day notice and comment period, formatting considerations or for the purpose of
clarifying or streamlining the content of the notice:
During the 60 day comment period, we had proposed to change the title of the
notice from “Medicare Prescription Drug Coverage and Your Rights” (per the
currently approved PRA package for CMS-10147) to “Notice: Your Prescription
Cannot be Filled”. Based on comments received, we will retain the current title of
“Medicare Prescription Drug Coverage and Your Rights”. Commenters believed
the proposed title may inappropriately suggest that the prescription couldn’t be
filled because the pharmacy made a coverage determination on behalf of the plan
or that the prescription not being filled was due to some other decision made by
the pharmacy. As a result of these and similar comments, we will retain the
existing title of CMS-10147.
As a result of comments received, we have added optional fields at the top of the
notice for the enrollee’s name and the drug and prescription number.
The numerical list under “What you need to do” has been reordered, per
comments received. Commenters suggested that the information specific to
asking for an exception be listed last (#4) since not all coverage determination
requests will involve an exception. Also as a result of comments received, the
phrasing of numbers 1, 2 and 3 has been revised to refer to the prescription that
was not filled so that the language is more closely tailored to the prescription
having been rejected at the pharmacy (not filled).
Language describing the right to request a coverage determination and an
exception has been consolidated for ease of reading under the section entitled

“Your Medicare rights”. We have also added language about the right to request
an expedited coverage determination under the “What you need to do” section.
The notice now clearly explains that if an exception is requested, the prescriber
will need to submit a supporting statement to the plan.
In addition to referring generally to plan materials and 1-800-Medicare if the
enrollee needs more information, we have added the more specific instruction to
contact the plan directly via the toll-free phone number on the membership card
or the plan’s website to request a coverage determination. These changes also
comport with the above-referenced regulatory provision.
This package incorporates minor formatting revisions to the form and the
instructions to better comply with 508 accessibility requirements.

The following changes have been made to the instructions based on regulatory changes:
Pursuant to the above-referenced regulatory provision, the option of posting the
standardized pharmacy notice has been eliminated. Beginning in plan year 2012,
pharmacies must now provide the enrollee with a printed copy of the pharmacy
notice if the prescription cannot be filled. This is reflected in the revised
instructions.
The following changes have been made to the instructions due to comments received
during the 60 day notice and comment period, formatting considerations or for reasons
other than regulatory changes:
The instructions clarify that the notice must be provided when an enrollee’s
prescription cannot be filled under the Medicare Part D benefit and the rejection
cannot be resolved at the point of sale. In other words, if there’s an initial
rejection (for example, due to a keying error) that is ultimately resolved and the
enrollee obtains his/her prescription drug, the notice does not need to be given to
the enrollee.
The instructions clarify that the written notice must be provided in a 12 point font.
The instructions explain that the fields at the top of the notice for the enrollee’s
name and the drug and prescription number are optional fields and may be
populated by the pharmacy.
This package incorporates minor formatting revisions to the form and the
instructions to better comply with 508 accessibility requirements.