Enrollee ’ s Name :___________________________________________________ ( Optional ) Drug and Prescription Number :_______________________________________ ( Optional )
Medicare Prescription Drug Coverage and Your Rights
Your Medicare rights
You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy . You also have the right to request a special type of coverage determination called an “ exception ” if you believe :
• you need a drug that is not on your drug plan ’ s list of covered drugs . The list of covered drugs is calleda “ formulary ;”
• a coverage rule ( such as prior authorization or a quantity limit ) should not apply to you for medicalreasons ; or
• you need to take a non-preferred drug and you want the plan to cover the drug at a preferred drug price .
What you need to do
You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan ’ s toll-free phone number on the back of your plan membership card , or by going to your plan ’ s website . You or your prescriber can request an expedited ( 24 hour ) decision if your health could be seriously harmed by waiting up to 72 hours for a decision . Be ready to tell your Medicare drug plan :
1 . The name of the prescription drug that was not filled . Include the dose and strength , if known . 2 . The name of the pharmacy that attempted to fill your prescription . 3 . The date you attempted to fill your prescription . 4 . If you ask for an exception , your prescriber will need to provide your drug plan with a statementexplaining why you need the off-formulary or non-preferred drug or why a coverage rule should notapply to you .
Your Medicare drug plan will provide you with a written decision . If coverage is not approved , the plan ’ s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan ’ s decision .
Refer to your plan materials or call 1-800-Medicare for more information .
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 . The valid OMB control number for this collection is 0938-0975 . The time required to complete this information collection is estimated to average 1 minute per response , including the time to review instructions , search existing data resources , and gather the data needed , and complete and review the information collection . If you have any 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 , Baltimore , Maryland 21244-1850 .
CMS does not discriminate in its programs and activities : To request this form in an accessible format ( e . g ., Braille , Large Print , Audio CD ) contact your Medicare Drug Plan . If you need assistance contacting your plan , call : 1-800-MEDICARE .
Form CMS -10147 OMB Approval No . 0938-0975 ( Expires : 02 / 28 / 2021 )
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