Form CMS-10147 Medicare Drug Coverage and Your Rights

Enrollee name: (optional)

Drug and prescription number: (optional)

Medicare Drug Coverage and Your Rights

You have the right to ask for a coverage determination from your Medicare drug plan to provide or pay for a drug you think should be covered, provided, or continued. You also have the right to ask for a special type of coverage determination called an “exception” if you:

• Need a drug that’s not on your plan’s list of covered drugs

• Believe a coverage rule (like prior authorization or a quantity limit) shouldn’t apply to you for medical reasons

• Need to take a non-preferred drug and you want the plan to cover the drug at a preferred drug price

How to ask for a coverage determination

To ask for a coverage determination, you or your prescriber can call your Medicare drug plan’s toll-free phone number on the back of your plan membership card, or go to your plan’s website. You can ask for an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision.

Be ready to tell your Medicare drug plan:

• The name of the prescription drug, including dose and strength (if known)

• The name of the pharmacy that tried to fill the prescription

• The date you tried to fill the prescription

• If you ask for an exception, your prescriber will need to explain why you need the off-formulary or non-preferred drug, or why a coverage rule shouldn’t apply to you

Your Medicare drug plan will send you a written decision. If coverage isn’t approved and you disagree with this decision, you have the right to appeal. The plan’s notice will explain why coverage was denied and how to ask for an appeal.

Get help and more information

Look at your plan materials or call 1-800-MEDICARE (1-800-633-4227) for more information about how to ask for a coverage determination. TTY users can call 1-877-486-2048. For help contacting your plan, call 1-800-MEDICARE.

Form CMS -10147 OMB Approval No. 0938-0975 (Expires: XX/XX/XXXX)

To get this form in an accessible format (like large print, Braille, or audio) contact your Medicare drug plan. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibilitynondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

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 information collection is 0938-0975. This information collection is used to provide notice to enrollees about how to contact their Part D plan to request a coverage determination. The time required to complete this information collection is estimated to average 1 minute per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required under § 423.562(a)(3) and an associated regulatory provision at § 423.128(b)(7)(iii). If you have 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form CMS -10147 OMB Approval No. 0938-0975 (Expires: XX/XX/XXXX)