CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk St

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

This is important information about your Medicare Part D prescription drug coverage.
Read this notice carefully. For help, please contact us. Please see ways to contacts us on the last page
under “For More Information and Help with This Notice.”
[Part D Plan Logo]
YOUR ACCESS TO CERTAIN PART D DRUGS IS LIMITED
Date: [insert date]
Enrollee’s Name: [insert name]

Member Number: [insert member ID]

[Insert the following language UNLESS the plan is continuing an existing limitation from the enrollee’s
immediately prior plan:] {On [insert date of initial notice], we told you that we planned to limit your
access to prescription [insert as appropriate: {opioids} or {benzodiazepines} or {opioids and
benzodiazepines}] through our drug management program. After completing our review, we have
determined that your use of these drugs is unsafe.}
[If the plan is continuing an existing limitation from the enrollee’s immediately prior plan, insert the
following language:] {You are getting this notice because your prior Medicare Part D plan, [Plan
Name], had placed you in its drug management program with a limitation(s) on your access to
prescription [insert as appropriate: {opioids} or {benzodiazepines} or {opioids and benzodiazepines}]
for your safety. Based on our review, including information obtained from your previous plan, we have
also placed you in our drug management program.}
What Action Have We Taken?
Effective immediately, your access to medications is limited in the following way(s):
[Insert the following language as applicable:]
{You will be required to get your prescription [insert as applicable: {opioids} or {benzodiazepines} or
{opioids and benzodiazepines}] from the following prescriber(s):
[insert name, address and telephone number of prescriber(s)]
We will not cover these medications at the pharmacy when they are prescribed to you by other doctors
[MA-PDs insert if applicable: {even if the other doctor is in our network}]. You can ask us to use a
different prescriber by contacting us or by filling out the form at the end of this notice.}
{You will be required to get your prescription [insert as applicable: {opioids} or {benzodiazepines} or
{opioids and benzodiazepines}] from the following pharmacy(ies):
[insert name, address and telephone number of pharmacy(ies)]
We will not cover these medications at another pharmacy, even if the other pharmacy is in the plan’s
network. You can ask us to use a different pharmacy by contacting us or by filling out the form at the
end of this notice.}
Form CMS-10141

OMB Approval No. 0938-0964 (Expires xx/xx/xxxx)

{We will only cover the following prescription opioid pain medication(s): [list medications and amounts,

if applicable]

We will not cover any other prescription opioid medications, even if they are included on the plan’s
drug list.}
{We will only cover the following amount of prescription opioid pain medication(s): [describe level that

plan will cover]}

{We will not cover any prescription opioid pain medication, including [insert beneficiary’s opioid
medication name(s)]. This includes opioids that are on the plan’s drug list.}
{We will only cover the following benzodiazepines: [list medications and amounts, if applicable]
We will not cover any other benzodiazepines, even if they are included on the plan’s drug list.}
{We will not cover any benzodiazepines, including [insert beneficiary’s benzodiazepine name(s)]. This
includes benzodiazepines that are on the plan’s drug list.}
This change only affects your access to prescription [insert as appropriate: {opioids} or
{benzodiazepines} or {opioids and benzodiazepines}]. Your access to other types of medications will
not change.
Why Did We Make This Decision?
[Provide specific rationale for the plan’s decision that the enrollee is an at-risk beneficiary and the
limitation(s) placed on the enrollee’s access to frequently abused drugs under the drug management
program. The rationale must include clinical criteria based on getting opioids from multiple prescribers
or pharmacies and/or a recent history of an opioid overdose, Medicare coverage rule, Part D plan policy
or other information on which the plan based its decision, including information obtained through case
management or subsequent clinical contact with the enrollee’s prescriber(s) of frequently abused drugs.
For decisions involving the continuation of a limitation under a drug management program from the
enrollee’s prior plan: the rationale must include an explanation, as applicable, that the plan’s decision to
continue the same limitation(s) as the prior plan was based in part on information obtained from the
prior plan.]
[Plan Name]’s drug management program helps you use prescription opioids safely. Opioid pain
medications can help with certain types of pain, but have serious risks like addiction, overdose, and
death. These risks are increased when opioids are obtained from multiple doctors or pharmacies; when
opioids are taken with certain other medications like benzodiazepines (commonly used for anxiety and
sleep); and/or when a person taking opioids has a recent history of opioid overdose.
Visit www.hhs.gov/opioids for information about State and Federal public health resources that can
help you learn more about opioid medications and how to use them safely. Also visit Medicare’s website
about pain management at https://www.medicare.gov/coverage/pain-management.
[PACE organizations omit this section. Insert this section for Low Income Subsidy (LIS) beneficiaries:]
{Can I Change Plans?
Generally no. As of [insert date of initial notice], you can only change plans during the year in very
Form CMS-10141

OMB Approval No. 0938-0964 (Expires xx/xx/xxxx)

limited situations, such as you move out of the plan’s service area or you lose or have a change in your
Extra Help with your prescription drug costs. You can also change plans during the Annual Enrollment
Period which occurs every year from October 15 – December 7.}
[Insert this section for pharmacy and/or prescriber limitation:]
{What If I Want to Use a Different [insert as appropriate: {Pharmacy} or {Prescriber} or
{Pharmacy or Prescriber}]?
If you don’t want to use the [insert as appropriate: {pharmacy} or {prescriber} or {pharmacy or
prescriber}] we selected for you, you can ask to use a different one. You can give us this information by
completing the last page of this notice and sending it to us, or by contacting us at the phone number
below.}
What If I Don’t Agree With This Decision?
You have the right to appeal. You can appeal our decision to limit your access to prescription [insert
as applicable: {opioids} or {benzodiazepines} or {opioids and benzodiazepines}], as well as any
coverage determination made under a drug management program.
If you change to a new Medicare plan, we can give your new plan information about your case and the
limits we have put on your access to prescription [insert as applicable: {opioids} or {benzodiazepines}
or {opioids and benzodiazepines}]. You also have the right to appeal our sharing of this information
with the new plan.
If you want to appeal, you must request your appeal by [insert date 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.
Who May Request an Appeal?
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 [insert toll free plan phone number] to learn how to appoint a representative. If
you have a hearing or speech impairment, please call us at TTY [insert 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.

Form CMS-10141

OMB Approval No. 0938-0964 (Expires xx/xx/xxxx)

•

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
information you’d like us to consider. You may wish to talk with your prescriber about your appeal.
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: [insert toll free phone number]
Fax: [insert fax number]
For a Standard Appeal: You, your prescriber, or your representative should mail or deliver
your written appeal request to the address below:
[Insert address]
What Happens Next?
If you appeal, we will review your case and give you a decision. If we continue to deny any part of your
request related to the limitations that apply to your access to medications, we will automatically send
your case to an independent reviewer outside of our plan. If you disagree with that decision, you will
have the right to another appeal. You will be notified of your appeal rights if this happens.
FOR MORE INFORMATION AND HELP WITH THIS NOTICE
For more information about the drug management program or any of the information in this notice,
please contact [Plan Name] at:
Toll Free: [Insert phone number]
TTY users: [Insert TTY]
[Insert call center hours of operation]
[Insert plan website]
[Insert plan mailing address]
[If the plan has a dedicated line (toll free), staff person, web portal, etc. for its DMP, that information
may be included in this section, as applicable.]
You may also contact one of the organizations listed below for assistance.
Form CMS-10141

OMB Approval No. 0938-0964 (Expires xx/xx/xxxx)

•
•
•

1-800-MEDICARE (1-800-633-4227), 24 hours, 7 days a week. TTY users: 1-877-486-2048
Medicare Rights Center: 1-888-HMO-9050
State Health Insurance Program National Technical Assistance Center: 877-839-2675

_______________________________________________
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 0938-0964. The time required to complete this information collection is estimated
to average 5 minutes 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-10141

OMB Approval No. 0938-0964 (Expires xx/xx/xxxx)

[Include the following form when the member has a pharmacy or prescriber limitation pending. This
form is not required when only medications are to be limited]
{[PLAN NAME] PHARMACY AND PRESCRIBER SELECTION FORM
Enrollee’s Name: [insert name]

Member Number: [insert member ID]

You can give us this information by calling us at [insert phone number], faxing this form to us at [insert
fax number], or by sending the completed form to: [insert address].
I prefer to use the following pharmacy (write in the information for up to two, in order of preference):
Choice #1
Pharmacy Name:
Address:
Telephone Number:
Choice #2
Pharmacy Name:
Address:
Telephone Number:

I prefer to use the following prescriber (write in the information for up to two, in order of preference):
Choice #1
Prescriber Name:
Address:
Telephone Number:

Choice #2
Prescriber Name:
Address:
Telephone Number:

Form CMS-10141

}
OMB Approval No. 0938-0964 (Expires xx/xx/xxxx)