Approved OMB #0938-0976
Notice of Denial of Medicare Prescription Drug Coverage
Member ID number:
We have denied coverage of the following prescription drug(s) that you or your physician
We denied this request because:
What If I Don’t Agree With This Decision?
You have the right to appeal. If you want to appeal, you must request your appeal within 60
calendar days after the date of this notice. We can give you more time if you have a good
reason for missing the deadline. You have the right to ask us for an exception if you believe
you need a drug that is not on our list of covered drugs (formulary) or believe you should get a
drug at a lower cost-sharing amount. You can also ask for an exception to utilization
management tools, such as a dose restriction or step therapy requirement. Your physician must
provide a statement to support your exception request.
Who May Request an Appeal?
You or someone you name to act for you (your appointed representative) may request an
appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for
you. Others may already be authorized under State law to act for you.
You can call us at: (______)_______________ to learn how to name your appointed
representative. If you have a hearing or speech impairment, please call us at
Form No. CMS-10146
IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTS
For more information about your appeal rights, call us or see your Evidence of Coverage.
There Are Two Kinds of Appeals
You Can Request
Expedited (72 hours) - You can request an
expedited (fast) appeal if you or your doctor
believe that your health could be s