CMS-10141 Model Prescriber Inquiry Letter

Medicare Prescription Drug Benefit Program - IRASA (CMS-10141)

Attachment 1e. Model Prescriber Inquiry Letter

OMB: 0938-0964

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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)
File Typeapplication/pdf
File TitleModel Prescriber Inquiry Letter
AuthorMDBG-DPDP
File Modified2021-10-14
File Created2021-10-14

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