Plan Sponsor Notices and Other Documents
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).
Downloads
-
Notice of Denial of Part D Prescription Drug Coverage CMS-10146 (with Instructions) (ZIP) -
Notice of Denial of Part D Prescription Drug Cvg CMS-10146 LARGE PRINT (with Instructions) (ZIP) -
Model Notice of Case Status_Feb2019v508 (ZIP) -
Medicare Prescription Drug Coverage and Your Rights (Form CMS-10147 and Instructions) (ZIP) -
Model Notice of Right Expedited Grievance_Part D_Feb2019v508 (ZIP) -
Model Request for Additional Information_Feb2019v508 (ZIP) -
Model Redetermination Notice_Feb2019 Maximus (ZIP) -
Model Redetermination Notice Jan 2021 C2C (ZIP) -
Model Notice of Inquiry_Feb2019v508 (ZIP) -
DMP Model Redetermination Notice (ZIP) -
Model Notice of Dismissal of Coverage Request_Dec2021v508 (ZIP) -
Part D - Model Notice of Dismissal of Appeal Request_Dec2021v508 (ZIP)