Form CMS-10147 Notice: Medicare Prescription Drug Coverage and Your Rig

Enrollee’s Name:

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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:
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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 a 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:
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The name of the prescription drug that was not filled. Include the dose and strength, if known.
The name of the pharmacy that attempted to fill your prescription.
The date you attempted to fill your prescription.
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.
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 collection is 0938-0975. The
time required to complete this information collection is estimated to average 1 minute per response, including the time to review
instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you
have any 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, Baltimore, Maryland 21244-1850.

CMS does not discriminate in its programs and activities: To request this form in an accessible format (e.g.,
Braille, Large Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting your plan,
call: 1-800-MEDICARE.
Form CMS -10147

OMB Approval No. 0938-0975 (Expires: XX/XX/2020)