Form CMS-10147 CMS-10147_Pharmacy_Notice_

OMB Approval No. 0938-0975

Enrollee’s Name:

(Optional)

Drug and Prescription Number:

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Medicare Prescription Drug Coverage and Your Rights
Your Medicare rights
You have the right to request a coverage determination from your Medicare drug
plan if you disagree with information provided by the pharmacy. You also have the
right to request a special type of coverage determination called an “exception” if
you believe:
you need a drug that is not on your drug plan’s list of covered drugs. The list of
covered drugs is called a “formulary;”
a coverage rule (such as prior authorization or a quantity limit) should not apply
to you for medical reasons; or
you need to take a non-preferred drug and you want the plan to cover the drug at
the preferred drug price.
What you need to do
You or your prescriber can contact your Medicare drug plan to ask for a coverage
determination by calling the plan’s toll-free phone number on the back of your plan
membership card, or by going to your plan’s website. You or your prescriber can
request an expedited (24 hour) decision if your health could be seriously harmed by
waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:
1. The name of the prescription drug that was not filled. Include the dose and
strength, if known.
2. The name of the pharmacy that attempted to fill your prescription.
3. The date you attempted to fill your prescription.
4. If you ask for an exception, your prescriber will need to provide your drug plan
with a statement explaining why you need the off-formulary or non-preferred drug
or why a coverage rule should not apply to you.
Your Medicare drug plan will provide you with a written decision. If coverage is not
approved, the plan’s notice will explain why coverage was denied and how to request
an appeal if you disagree with the plan’s decision.
Refer to your plan materials or call 1-800-Medicare for more information.
Form CMS -10147