CMS-10141 Model Prescriber Inquiry Letter

Model Part D Drug Management Program Prescriber Inquiry Letter
Instructions: This model could be used to notify prescribers of frequently abused drugs that their
patient’s utilization pattern of frequently abused drug(s) and/or their history of opioid-related
overdose is potentially unsafe and has prompted a case management review under the plan’s
Drug Management Program. Plans may use all or part of the language in this model, modify the
language, or create their own language.

RE:
Dear [PRESCRIBER NAME]:
is sending you this letter to request your assistance and response. We are the
Medicare prescription drug benefit plan for your patient, . We have
important information, of which you may or may not be aware, about their utilization of
prescription < or or >. The information may assist you in treating this patient. Under our
Drug Management Program, we review opioid utilization by plan enrollees that involves
multiple prescribers and/or pharmacies, and/or a history of opioid-related overdose, and
identifies potentially unsafe utilization for case management.
information about the
medications prescribed for of which we are aware, including the
prescriber(s), dosage(s) (quantities and days’ supply) prescribed, dispensing dates and time
period we are reviewing.>
We would appreciate your review of the total prescription drug utilization of this patient, and your opinion whether they are at-risk for prescription drug misuse or
abuse. We are also interested in learning other relevant information from you, including whether
they are being treated for active cancer-related pain, receiving hospice, palliative, or end-of-life
care services, or have sickle cell disease. If they are at-risk, we would like to work with you {and
the other prescribers of these drugs} to determine how their utilization of these drugs should be
more closely managed.
When multiple prescribers are involved, the goal of our Drug Management Program is to obtain
input from all prescribers regarding the appropriate, medically necessary, and safe utilization for
the patient, and determine whether a coverage limitation might assist you in managing their safe
use of <> <>. If we are unable to establish through
Form CMS-10141

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

communication with prescriber(s) that this individual’s current use of prescription opioid
medication(s) is appropriate, medically necessary, and safe, we may decide to place a limitation
on their coverage of some or all of these medications. Therefore, your input is imperative.
We encourage you to use your state’s Prescription Drug Monitoring Programs (PDMP) prior to
prescribing to assess your patient’s history of controlled substance use. The database may
include additional controlled substance prescriptions not covered by this plan, such as those
where the patient paid out of pocket. As an additional tool to consider in managing your patient’s
safe use of opioids, we would like to make you aware of the opioid reversal agent(s) available on
the formulary. We encourage you to consider co-prescribing an opioid reversal
agent when prescribing opioids to your patients for their safety:
, [Add lines as appropriate]
We thank you for your assistance in addressing this matter and urge you to be responsive. Please
provide us with the information requested and/or return this page to us by .
Should you have any questions, or if you need additional information, please contact me at
during the hours of and please refer to the file number
above.
Sincerely,

_____________________________________________________________________________
[Insert beneficiary identifying information]
[List or attach the pertinent opioid/benzodiazepine prescription information].
[For beneficiaries identified has having a history of opioid overdose, suggested adding this or a
similar statement: Based on a review of administrative claims, it appears
may have experienced an opioid-related overdose event within the last 12 months and was
prescribed opioids within the last 6 months.
PLEASE COMPLETE ALL THAT APPLY. THANK YOU FOR YOUR
COOPERATION.
___ I would like to contact me further to discuss this case, including relevant
treatment information.
___ I, am of the opinion that: 1) all these medications are appropriate,
medically necessary, and safe for my patient, ; and 2)
IS NOT at-risk for prescription drug abuse or misuse.

Form CMS-10141

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

___ I am of the opinion that: 1) all of these medications are NOT
appropriate, medically necessary, and safe for my patient, ; and 2)
IS at-risk for prescription drug abuse or misuse.
___I think should be aware of the following relevant treatment 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 0938-0964. If you have any 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)