Form CMS-10146 NOTICE OF DENIAL OF MEDICARE PRESCRIPTION DRUG COVERAGE

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0976

Important: This notice explains your right to appeal our decision. Read this notice carefully. If you
need help, you can call one of the numbers listed on the last page under “Get help & more information.”
[Logo]

NOTICE OF DENIAL OF MEDICARE PRESCRIPTION DRUG COVERAGE
Date:

Enrollee's Name:

Member Number:

Your request was denied
We have denied coverage or payment under your Medicare Part D benefit for the following prescription drug(s) that
you or your prescriber requested:

Why did we deny your request?
We denied this request under Medicare Part D because{Provide specific rationale for denial including any applicable
Medicare coverage rule or Part D plan policy.}:

{Optional language that should be inserted as applicable}
{Although your drug was denied under your Medicare Part D benefit, it may be covered under another benefit (i.e.
Medicare Part B). Please call 1-800-Medicare for more information.} Or call {insert plan number}.
{Medicare Part D has denied your request, however, {insert benefit} has approved coverage/payment for the
requested drug(s) {explain the conditions of approval in a readable and understandable format} If you think
Medicare Part D should have paid- you may appeal.

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?

Form CMS-10146 (02/11)

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: (
)
.

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:
{Insert address}

Form CMS-10146 (02/11)

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.
Get help & more information

• {Plan Name} Toll Free:
TTY users call:
{Insert call center hours of operation}
{Insert plan website}
• 1-800-MEDICARE (1-800-633-4227), 24 hours, 7 days a week. TTY users call: 1-877-486-2048
• Medicare Rights Center: 1-888-HMO-9050
• Elder Care Locator: 1-800-677-1116

Form CMS-10146 (02/11)