Standardized Pharmacy Notice

Form Instructions
Medicare Prescription Drug Coverage and Your Rights
Standardized Pharmacy Notice (CMS-10147)

Each Medicare Part D plan sponsor must arrange with its network pharmacies, including mail
order and specialty pharmacies, for the distribution of this notice to Part D enrollees when a
prescription cannot be covered (“filled”) under the Medicare Part D benefit at the point of sale
(POS). The notice must be provided to the enrollee if the pharmacy receives a transaction
response (rejected or paid) indicating the claim is not covered by Part D. See Chapter 18,
Notification by Network Pharmacists, of the Prescription Drug Benefit Manual for the complete
list of rejected claim scenarios where delivery of this notice is not required. The notice instructs
enrollees about their right to contact their Part D plan to request a coverage determination,
including an exception. This notice fulfills the requirements at 42 CFR § 423.562(a)(3) and §
423.128(b)(7)(iii).
This is a standardized notice, the content of which may not be altered. The notice must be
provided in 12 point font. The OMB control number must be displayed in the lower right corner
of the notice. The fields for the enrollee’s name and the drug and prescription number are
optional and may be populated by the pharmacy.
Heading
Logo not required. Pharmacies may place their logo in the space above the optional fields for the
enrollee’s name and the drug and prescription number.

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 information collection is 0938-0975. The time required to complete this
information collection is estimated to average one (1) minute per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. 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 Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form CMS -10147

OMB Approval No. 0938-0975 (Expires: XX/XX/2020)