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

When a pharmacy receives a rejection for a claim not being covered by Medicare Part D, the pharmacy must provide the patient with the CMS-10147 form, also known as the Medicare Prescription Drug Coverage and Your Rights. All pharmacies, including mail order, specialty, and LTC, must arrange for this form to be distributed to the patient. The notice instructs enrollees about their right to contact their Part D plan to request a coverage determination, including an exception.

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.

PAAS Tips:

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  • 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 copies of the notice in both English and Spanish, along with accompanying instructions
  • PAAS FWA/HIPAA Compliance Program members should review section 4.5 of their PAAS National® FWA/HIPAA Policy and Procedure manual
  • NCPDP reject code 569 requires distribution of the form and should state “Provide Notice: Medicare Prescription Drug Coverage and Your Rights”
  • The CMS-10147 form must be distributed even if you obtain an alternative therapy or medication
  • Obtaining a prior authorization does not waive the distribution requirement
  • Check with your pharmacy software vendor to see if the program can automatically print a copy of the CMS-10147 when required

Jenevra Azzopardi, CPhT