Enrollee name: __________________________________________________________________________________( optional) Drug and prescription number: ___________________________________________________________________( optional) Medicare Drug Coverage and Your Rights
Enrollee name: __________________________________________________________________________________( optional) Drug and prescription number: ___________________________________________________________________( optional) Medicare Drug Coverage and Your Rights
You have the right to ask for a coverage determination from your Medicare drug plan to provide or pay for a drug you think should be covered, provided, or continued. You also have the right to ask for a special type of coverage determination called an“ exception” if you:
• Need a drug that’ s not on your plan’ s list of covered drugs
• Believe a coverage rule( like prior authorization or a quantity limit) shouldn’ t apply to you for medical reasons
• Need to take a non-preferred drug and you want the plan to cover the drug at a preferred drug price
How to ask for a coverage determination To ask for a coverage determination, you or your prescriber can call your Medicare drug plan’ s toll-free phone number on the back of your plan membership card or go to your plan’ s website. You can ask for 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:
• The name of the prescription drug, including dose and strength( if known)
• The name of the pharmacy that tried to fill the prescription
• The date you tried to fill the prescription
• If you ask for an exception, your prescriber will need to explain why you need the off-formulary or nonpreferred drug, or why a coverage rule shouldn’ t apply to you
Your Medicare drug plan will send you a written decision. If coverage isn’ t approved and you disagree with this decision, you have the right to appeal. The plan’ s notice will explain why coverage was denied and how to ask for an appeal.
Get help and more information Look at your plan materials or call 1-800-MEDICARE( 1-800-633-4227) for more information about how to ask for a coverage determination. TTY users can call 1-877-486-2048. For help contacting your plan, call 1-800-MEDICARE.
To get this form in an accessible format( like large print, Braille, or audio) contact your Medicare drug plan. You also have the right to file a complaint if you feel you’ ve been discriminated against. Visit Medicare. gov / aboutus / accessibility-nondiscrimination-notice or call 1-800-MEDICARE( 1-800-633-4227) for more information. TTY users can call 1-877-486-2048.
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 0MB control number. The valid 0MB control number for this information collection is 0938-0975. This information collection is used to provide notice to enrollees about how to contact their Part D plan to request a coverage determination. 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, gather the data needed, to review and complete the information collection. This information collection is required under § 423.562( a)( 3) and an associated regulatory provision at § 423.128( b)( 7)( iii). If you have 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 0fficer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
PRA Disclosure Statement Form CMS-10147 OMB Approval No. 0938-0975( Expires: 12 / 31 / 2027) uabmedicine. org / uab-home-infusion-therapy 23