Form CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co

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

Important: This notice explains your right to appeal our decision. Read this notice carefully. If you
need help, you can call one of the numbers listed under the section titled “Get help & more
information.”

[Logo]

NOTICE OF DENIAL OF MEDICARE PART D PRESCRIPTION DRUG COVERAGE
Date:

Enrollee's Name:

Member Number:

Your request was denied
We have denied coverage or payment under your Medicare Part D benefit for the following prescription drug(s)
that you or your prescriber requested:

Why did we deny your request?
We denied this request under Medicare Part D because {Provide specific rationale for the denial, including any
applicable Medicare coverage rule or Part D plan policy. See instructions for additional detail.}:

You should share a copy of this decision with your prescriber so you and your prescriber can discuss next steps.
If your prescriber requested coverage on your behalf, we have shared this decision with your prescriber.
[Language to be inserted, as applicable, for prescription drugs that are or may be covered under
Medicare Parts A or B]:
[Medicare Advantage plans that also provide Part D coverage (MA-PDs):] {This request was denied under your
Medicare Part D benefit; however, coverage/payment for the requested drug(s) has been approved under
Medicare Part A/B {explain the conditions of approval in a readable and understandable format}. If you think
Medicare Part D should cover this drug for you, you may appeal.}
[Standalone Part D plans (PDPs):] {This request was denied under your Medicare Part D benefit; however, it
may be covered under Medicare Part A or Part B. For more information, talk to your prescriber or call 1-800MEDICARE. }

Form CMS-10146

OMB Approval No. 0938-0976 (Expires 06/30/2027)

What If I Don’t Agree With This Decision?
You have the right to appeal. If you want to appeal, you must request your appeal within
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. You have the right to ask us for a formulary exception if you believe you need a
drug that is not on our list of covered drugs (formulary). You have the right to ask us for a coverage rule
exception if you believe a rule such as prior authorization or a quantity limit should not apply to you. You
can either provide information that shows that you meet the coverage rule that applies to the drug you are
requesting or you can ask for a coverage rule exception. You can ask for a tiering exception if you
believe you should get a drug at a lower cost-sharing amount. Your prescriber must provide a statement to
support your exception request.
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: (
)
to learn how to appoint a representative. If you have a
hearing or speech impairment, please call us at 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.
 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. If your appeal is for payment of a drug
you’ve already received, we’ll give you a written decision within 14 days.
What Do I Include with My Appeal Request?
You should include your name, address, Member number, the reasons for appealing, and any evidence
you wish to attach. Remember, your doctor must provide us with a supporting statement if you’re
requesting an exception to a coverage rule. You should include information about why the coverage rule
should not apply to you because of your specific medical condition. If your appeal relates to a decision by
us to deny a drug that is not on our formulary, your prescriber must indicate that all the drugs on any tier
of our formulary would not be as effective to treat your condition as the requested off-formulary drug or
would harm your health.

Form CMS-10146

OMB Approval No. 0938-0976 (Expires 06/30/2027)

How Do I Request an Appeal?
For an Expedited (Fast) Appeal: You, your prescriber, or your representative can file an appeal by
telephone, by fax, through the plan’s website, or by mail. A verbal request by telephone is the
fastest way to file an expedited (fast) request.
Phone:
TTY:
For a Standard Appeal: [For plans that accept verbal standard requests:] {You, your prescriber, or
your representative can file an appeal by telephone, by fax, through the plan’s website, or by sending a
letter to the mailing address listed below.}
[For plans that do not accept verbal standard requests:] {You, your prescriber, or your representative
can file an appeal by fax, through the plan’s website, or by sending a letter to the mailing address listed
below.}
[For plans that do not accept verbal standard requests, omit the plan phone number and TTY]
{Phone:}
{TTY:}
Fax:
Plan Website:
Address:

What Happens Next?
If you appeal, we will review your case and give you a decision. If any of the prescription drugs you
requested are still denied, you can request an independent review of your case by a reviewer outside
of your Medicare Drug Plan. If you disagree with that decision, you will have the right to further appeal.
You will be notified of your appeal rights if this happens.

Get help & more information
 {Plan Name} Toll Free:
TTY users call:
{Insert call center hours of operation}
{Insert plan website}
 1-800-MEDICARE (1-800-633-4227), 24 hours, 7 days a week. TTY users call: 1-877-486-2048
 Medicare Rights Center: 1-888-HMO-9050 (1-888-466-9050)
 Elder Care Locator: 1-800-677-1116
 State Health Insurance Program National Technical Assistance Center: 877-839-2675
Form CMS-10146

OMB Approval No. 0938-0976 (Expires 06/30/2027)

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 0938-0976. The time required to complete this
information collection is estimated to average 30 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.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also
have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/aboutus/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY
users can call 1-877-486-2048.

Form CMS-10146

OMB Approval No. 0938-0976 (Expires 06/30/2027)