OMB control number
Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)
OMB 0938-0976 · HHS/CMS.
OMB 0938-0976
Pursuant to 42 CFR 423.568(e) and (f), if a Part D plan denies drug coverage it must give the enrollee written notice of the adverse coverage determination. The form and content of the written denial notice must comport with specific requirements, including a description of the appeals process.
The latest form for Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146) expires 2027-11-30 and is listed under ICR 202409-0938-015.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146) | Form |
| CMS-10146 - Supporting Statement_ Clean.docx | Supporting Statement A |
 CMS-10146 B- Crosswalk_508.pdf | Supplementary Document |
| CMS Response to Public Comments - CMS-10146.docx | Supplementary Document |
 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146) |
Form |