Medicare Prescription Drug Coverage and Your Rights (CMS-10147)

When a pharmacy receives an NCPDP Reject Code 569 <Provide Notice: Medicare Prescription Drug Coverage and Your Rights> on a Medicare Part D claim, the pharmacy “must” provide the patient with the CMS-10147 form, also known as the Medicare Prescription Drug Coverage and Your Rights notice. The notice instructs enrollees about their right to contact their Part D plan to request a “coverage determination” or prior authorization.

In general, all pharmacies must arrange for this form to be distributed to the patient. While retail pharmacies must provide the notice at point-of-sale, mail order and specialty pharmacies have up to 72 hours to provide it to the patient. Importantly, CMS recognizes the uniqueness of LTC settings and that there is no practical means to deliver the notice directly to the patient; as a result, if the pharmacy can resolve the matter and ensure the LTC patient receives the needed medication or an appropriate substitute, they do not need to deliver the notice. If the matter cannot be resolved, then the pharmacy must deliver the notice within 72 hours to the patient, patient’s representative, prescriber or appropriate staff person at the LTC facility.

The 569 reject will NOT be returned in the following scenarios:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Join today!

  • Claim rejects only because it does not contain all necessary data elements for adjudication;
  • Drug in question is an OTC drug that is not covered by the member’s Part D plan;
  • Prescription is written by a sanctioned provider who has been excluded from participation in the Medicare program;
  • Drug is not listed on the participating CMS Manufacturer Labeler Code List;
  • Drug is not listed on the FDA Electronic List—NDC Structured Product Labeling Data Elements File (NSDE);
  • The Part D plan rejects the claim for the drug in question only because of NCPDP Reject Code 79 <Refill too soon/early refill> edit;
  • Drug in question is rejected by the Part D plan benefit but is covered by a co-administered insured benefit managed by a single processor. In this scenario, the pharmacy submits a single claim transaction for the drug and the drug is covered by the co-administered insured benefit after being rejected by Part D and processed in accordance with the benefits offered by the supplemental payer.

While documentation is not required when distributing the CMS-10147, your pharmacy should have a policy and procedure in place addressing how and when the form is being distributed to patients. PBM field auditors may ask you questions about your process and will possibly want to see a copy of your form to ensure you have the most up-to-date version. OptumRx auditors may even look to see if you have a copy of the CMS-10147 posted in the pharmacy. However, the OptumRx Provider Manual does not require the form to be posted, and Chapter 18 of the Prescription Drug Benefit Manual does not obligate the pharmacy to post the notice.

PAAS Tips:

  • Download the current version of the Medicare Prescription Drug Coverage and Your Rights (Form CMS-10147) at https://www.cms.gov/medicare/appeals-grievances/prescription-drug/plan-sponsor-notices-documents
    • The zip file includes instructions as well as MS Word and PDF versions of the notice in English, Spanish, Korean, Chinese, and Vietnamese
  • The CMS-10147 must be distributed even if you obtain an alternative therapy or prior authorization is approved (LTC exception)
  • Posting the CMS-10147 notice does not satisfy Medicare requirements
  • Check with your pharmacy software vendor to see if the program can automatically print a copy of the CMS-10147 when required
  • PAAS FWA/HIPAA Compliance Program members should review section 4.5 of their PAAS National® FWA/HIPAA Policy and Procedure manual

Eric Hartkopf, PharmD
Latest posts by Eric Hartkopf, PharmD (see all)