Standardized Pharmacy Notice

Form Instructions

Medicare Prescription Drug Coverage and Your Rights

Standardized Pharmacy Notice (CMS-10147)

Each Medicare Part D plan sponsor must arrange with its network pharmacies for the distribution of this notice to Part D enrollees when a prescription cannot be covered (“filled”) under the Medicare Part D benefit at the point of sale (POS). The notice must be provided to the enrollee if the pharmacy receives a transaction response (rejected or paid) indicating the claim is not covered by Part D. The notice instructs enrollees about their right to contact their Part D plan to request a coverage determination, including an exception. This notice fulfills the requirements at 42 CFR § 423.562(a)(3) and § 423.128(b)(7)(iii).

This is a standardized notice, the content of which may not be altered. The notice must be provided in 12 point font. The OMB control number must be displayed in the upper right corner of the notice. The fields for the enrollee’s name and the drug and prescription number are optional and may be populated by the pharmacy.

Heading

Logo not required. Pharmacies may place their logo in the space above the optional fields for the enrollee’s name and the drug and prescription number.

PRA Disclosure Statement

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 (1) minute per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.