Medicare Prescription Drug Coverage and Your Rights (CMS-10147)

OMB 0938-0975

Pursuant to 42 CFR 423.562(a)(3) and 423.128(b)(7)(iii), Part D plan sponsors must arrange with their network pharmacies to provide a printed copy of the standardized pharmacy notice to enrollees (beneficiaries) at the point of sale when an enrollee's prescription cannot be filled.

The latest form for Medicare Prescription Drug Coverage and Your Rights (CMS-10147) expires 2021-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10147 Standardized Pharmacy Notice Form
CMS-10147 - Supporting Statement A.docx Supporting Statement A
Standardized Pharmacy Notice Form

All Historical Document Collections

202103-0938-014 Approved without change	Reinstatement without change of a previously approved collection	2021-03-26
201804-0938-011 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-04-17
201709-0938-002 Approved with change	Revision of a currently approved collection	2017-09-21
201408-0938-016 Approved without change	Extension without change of a currently approved collection	2014-08-29
201203-0938-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2012-03-10
201109-0938-005 Approved with change	Revision of a currently approved collection	2011-09-21
200809-0938-001 Approved without change	Extension without change of a currently approved collection	2008-09-04
200603-0938-012 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-03-22
200509-0938-015 Approved with change	New collection (Request for a new OMB Control Number)	2005-09-30