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. If an enrollee’s prescription cannot be
filled under the Medicare Part D benefit and the rejection cannot be resolved at point of
sale, the pharmacy must provide the enrollee with this written notice in 12 point font.
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 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.