Instructions for Drug Management Program Notices

Form Instructions for Drug Management Program Beneficiary Notices
CMS-10874
These notices must comply with all requirements at 42 CFR § 423.153(f) and these instructions.
The language in these notices is not model language. These are standard forms. Part D plan
sponsors may not deviate from the content provided. The notices contain italicized text in curly
brackets “{ }” to be inserted when applicable to the situation. Bracketed text “[ ]” that is not
italicized provides instruction on text to be inserted in the notice.
Please note that the OMB control number must be displayed in the lower right corner of the
notice.
Initial Notice (“NOTICE OF INTENT TO LIMIT YOUR ACCESS TO CERTAIN PART
D DRUGS”)
When a Part D plan sponsor determines that an enrollee is potentially at risk for prescription drug
abuse under 42 CFR §423.153(f) and intends to limit the enrollee’s access to frequently abused
drugs under Part D, the plan sponsor must issue this notice to the affected enrollee. Specific
instructions on optional language and fillable fields can be found within the notice.
Second Notice (“YOUR ACCESS TO CERTAIN PART D DRUGS IS LIMITED”)
When a Part D plan sponsor determines that an enrollee is at risk for prescription drug abuse
under 42 CFR §423.153(f), the plan sponsor must issue this notice to the affected enrollee before
or concurrent with implementing a limitation on the enrollee’s access to frequently abused drugs
under its drug management program. Specific instructions on optional language and fillable
fields can be found within the notice.
Alternate Second Notice (“YOUR ACCESS TO CERTAIN PART D DRUGS WILL NOT
BE LIMITED”)
When, after issuing the Initial Notice described above, a Part D plan sponsor determines that an
enrollee is NOT at risk for prescription drug abuse under 42 CFR §423.153(f) and will not limit
the enrollee’s access to frequently abused drugs under its drug management program, the Part D
plan sponsor must issue this notice to the enrollee. Specific instructions on optional language
and fillable fields can be found within the notice.
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-TBD The time required to complete this information collection
is estimated to average 5 minutes per response (each notice), 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.

Form CMS-10874

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

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-10874

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