Plan Sponsor Notices and Other Documents
Guidance for a number of notices and other documents for plan sponsors.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 24, 2020
This page includes a number of notices and other documents for plan sponsors. Questions regarding any of the Part D notices can be submitted through this link: https://appeals.lmi.org/
Standardized Notices
CMS has developed the following standardized notices to be used by plan sponsors:
- Medicare Prescription Drug Coverage and Your Rights ("Pharmacy Notice")
- Notice of Denial of Medicare Part D Prescription Drug Coverage
Medicare Prescription Drug Coverage and Your Rights (CMS-10147)
The standardized notice Medicare Prescription Drug Coverage and Your Rights (CMS-10147) ("pharmacy notice") and form instructions are available in the "Downloads" section below.).
Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146)
The Notice of Denial of Medicare Part D Prescription Drug Coverage, both in English and Spanish, which includes the corresponding instructions is available in the "Downloads" section below.
April 30, 2024: The OMB-approved Notice of Denial of Medicare Part D Prescription Drug Coverage notice has been updated to display the new expiration date of 12/31/2024.
Model Notices
CMS model notices contain all of the elements CMS requires for proper notification to enrollees or prescribers, if applicable. Plan sponsors may modify the model notices and submit them to the appropriate CMS regional office for review and approval. Plan sponsors may use these notices at their discretion.
NOTE REGARDING MEDICARE NOTICES WITH QIO INFORMATION:
Providers, suppliers, Medicare Advantage Organizations and Prescription Drug Plans should make certain that their Medicare notices include the correct Quality Improvement Organization (QIO) contact information. Please see www.qioprogram.org for QIO details.
The following model notices are available in both Microsoft Word and PDF formats in the "Downloads" section below:
- Notice of Right to an Expedited Grievance
- Model Redetermination Notice
- Notice of Case Status
- Request for Additional Information
- Notice of Inquiry
- DMP Model Redetermination Notice
- Notice of Dismissal of Coverage Request
- Notice of Dismissal of Appeal Request
CMS has published additional guidance through the Health Plan Management System (HPMS) that clarifies a number of issues related to Part D grievances, coverage determinations, and appeals (see "HPMS Guidance History" in the "Related Links" section below).
HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.