This page includes a number of notices and other documents for plan sponsors.

Standardized Notices

CMS has developed the following standardized notices to be used by plan sponsors:

• Notice of Denial of Medical Coverage and Notice of Denial of Payment
• Medicare Prescription Drug Coverage and Your Rights

To view the standardized notices, click on the links in the "Downloads" section below.

Model Notices

The following model notices are contained in the appendices to Chapter 18 of the Prescription Drug Benefit Manual:

• Appendix 3 - Notice of Right to an Expedited Grievance
• Appendix 4 - Notice of Redetermination
• Appendix 6 - Notice of Case Status
• Appendix 7 - Notice of Plan's Decision to Extend the Deadline for Making a Decision Regarding a Grievance
• Appendix 8 - Notice of Plan's Decision Regarding a Grievance
• Appendix 9 - Notice of Effectuation to Part D Independent Review Organization
• Appendix 10 - Notice of Formulary or Cost-sharing Change
• Appendix 11 - Request for Additional Information
• Appendix 12 - Notice of Inquiry Regarding an Excluded Drug
• Appendix 13 - Request for Reconsideration

To view Microsoft Word versions of the model notices, click on the "Model Notices" link in the "Downloads" section below. PDF versions of the model notices can be obtained by clicking on the link to Chapter 18 in the "Downloads" section below and scrolling through the document to the appropriate appendix.

CMS has published additional guidance through the Health Plan Management System (HPMS) that clarifies a number of issues related to Part D grievances, coverage determinations, and appeals.  To view all the guidance released through HPMS, click on the related link in the "Related Links Inside CMS" section below.

Downloads
Notice of Denial of Medical Coverage and Notice of Denial of Payment [zip, 9kb] Instructions for Using the Notice of Denial of Medical Coverage and Notice of Denial of Payment [pdf, 17kb] Medicare Prescription Drug Coverage and Your Rights [zip, 7kb] Instructions for Using Medicare Prescription Drug Coverage and Your Rights [pdf, 12kb] Spanish - Notice of Denial of Medical Coverage and Notice of Denial of Payment with Instructions [zip, 51kb] Spanish - Medicare Prescription Drug Coverage and Your Rights with Instructions [zip, 63kb] Model Notices [zip, 41kb] Chapter 18 of the Prescription Drug Benefit Manual [pdf, 384kb]
Related Links Inside CMS
CMS guidance released through HPMS
Related Links Outside CMS
There are no Related Links Outside CMS

Page Last Modified: 08/31/2006 3:02:00 PM
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