Standardized Pharmacy Notice

Form Instructions

Medicare Drug Coverage and Your Rights

Standardized Pharmacy Notice (CMS-10147)

Each Medicare Part D plan sponsor must arrange with its network pharmacies, including mail order and specialty pharmacies, for the distribution of this notice to Part D enrollees when a prescription cannot be covered (“filled”) under the Medicare Part D benefit at the point of sale (POS). The notice must be provided to the enrollee if the pharmacy receives a transaction response (rejected or paid) indicating the claim is not covered by Part D. See Chapter 18, Notification by Network Pharmacists, of the Prescription Drug Benefit Manual for the complete list of rejected claim scenarios where delivery of this notice is not required. The notice instructs enrollees about their right to contact their Part D plan to request a coverage determination, including an exception. This notice fulfills the requirements at 42 CFR § 423.562(a)(3) and § 423.128(b)(7)(iii).

This is a standardized notice, the content of which may not be altered. The notice must be provided in 12 point font. The OMB control number must be displayed in the lower right corner of the notice. The fields for the enrollee’s name and the drug and prescription number are optional and may be populated by the pharmacy.

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Logo not required. Pharmacies may place their logo in the space above the optional fields for the enrollee’s name and the drug and prescription number.

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. This is a national survey that will be conducted with consumers who currently have health insurance through the Health Insurance Marketplace or are uninsured, and people who currently have Medicare. The survey is designed to examine confidence in making healthcare decisions, confidence in ability to understand key health insurance concepts, health insurance knowledge, and health insurance decision making specific to the Health Insurance Marketplace and Medicare. Utilizing the answers from the confidence and health insurance knowledge sections, will give insight regarding how health insurance literacy impacts health insurance decisions. The valid OMB control number for this information collection is 0938-0975. The time required to complete this voluntary, non-confidential information collection is estimated to average 1 minute per survey, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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)