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Express Communications
12-31-13
Page 1 of 3
Updated Guidance for Medicare Part D Pharmacy Notice
On July 1, 2013, guidance from the Centers for Medicare and Medicaid Services (CMS) concerning
distribution of the Standardized Pharmacy Notice (CMS-10147) became effective, and CMS revised its
requirements for distributing this Standardized Pharmacy Notice (CMS-10147 “Medicare Prescription Drug
Coverage and Your Rights”).
All network pharmacies are required to provide Medicare Part D enrollees with a written copy of the
“Medicare Prescription Drug Coverage and Your Rights” notice when an enrollee’s prescription cannot be
filled under the Part D benefit and the issue cannot be resolved. Express Scripts will return Reject Code
569 (Provide Notice: Medicare Prescription Drug Coverage and Your Rights) when the pharmacy should
provide this notice to the beneficiary.
Highlights of the Revised Guidance for Distribution of Standardized Pharmacy Notice
72-Hour Turn-around Time for Home Infusion and Long Term Care Pharmacies
Home Infusion
LTC Pharmacy
The pharmacy may also choose to provide the
notice in person with delivery of home infusion
drugs or through an infusion nurse, as long as
the next scheduled visit is within 72 hours of
receipt of the transaction code indicating the
claim cannot be covered by Medicare Part D.
If the pharmacy must fax or otherwise deliver
the notice to the enrollee, the enrollee’s
representative, prescriber or an appropriate staff
person at the LTC facility as expeditiously as the
enrollee’s health condition requires, but no later
than 72 hours from the pharmacy’s receipt of
the original transaction response.
Changes also include a modification of the standard NCPDP Reject Code 569 message removing
the words “appeal rights.” The new NCPDP standardized message for Reject Code 569 is “Provide
Notice: Medicare Prescription Drug Coverage and Your Rights.”
When the following situations occur, Express Scripts will NOT return a Reject Code 569 (Provide Notice:
Medicare Prescription Drug Coverage and Your Rights) and pharmacies will not need to provide the
pharmacy notice to beneficiaries:
The claim rejects only because it does not contain all necessary data elements for adjudication;
The drug in question is an over-the-counter (OTC) drug not covered by the enrollee’s Part D plan;
The prescription is written by a sanctioned prescriber who has been excluded from participation in
the Medicare program;
The drug is not listed on the participating CMS Manufacturer Labeler Code List;
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All Rights Reserved.
Express Communications
12-31-13
Page 2 of 3
Updated Guidance for Medicare Part D Pharmacy Notice (Continued)
The drug is not listed on the participating CMS Manufacturer Labeler Code List;
The drug is not listed on the Food and Drug Administration (FDA) Electronic List—NDC Structured
Product Labeling Data Elements File (NSDE);
The Part D Pan rejects the claim because of a “refill too soon/early refill” edit; or
The drug in question is not covered 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.
Pharmacies may visit the website http://www.cms.gov/Medicare/Appeals-andGrievances/MedPrescriptDrugApplGriev/PlanNoticesAndDocuments.html to obtain a current copy of the
“Medicare Prescription Drug Coverage and Your Rights” notice and accompanying instructions for its use.
(A copy of the form is included on the next page of this document.)
Questions may be directed to 800.824.0898 or 800.922.1557.
NOTE: Medco Health Solutions, Inc. (“Medco”) is a wholly-owned subsidiary of Express Scripts Holding Company
(“Express Scripts”). BINs 610014 and 003858 are Express Scripts BINs; please update your software if needed to show
both BINs as Express Scripts. Please refer to the member ID card for the correct BIN when processing a claim.
Confidential & Proprietary
© 2013 Express Scripts Holding Company.
All Rights Reserved.
OMB Approval No. 0938-0975
Enrollee’s Name:
(Optional)
Drug and Prescription Number:
(Optional)
Medicare Prescription Drug Coverage and Your Rights
Your Medicare rights
You have the right to request a coverage determination from your Medicare drug
plan if you disagree with information provided by the pharmacy. You also have the
right to request a special type of coverage determination called an “exception” if
you believe:



you need a drug that is not on your drug plan’s list of covered drugs. The list of
covered drugs is called a “formulary;”
a coverage rule (such as prior authorization or a quantity limit) should not apply
to you for medical reasons; or
you need to take a non-preferred drug and you want the plan to cover the drug at
the preferred drug price.
What you need to do
You or your prescriber can contact your Medicare drug plan to ask for a coverage
determination by calling the plan’s toll-free phone number on the back of your plan
membership card, or by going to your plan’s website. You or your prescriber can
request an expedited (24 hour) decision if your health could be seriously harmed by
waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:
1. The name of the prescription drug that was not filled. Include the dose and
strength, if known.
2. The name of the pharmacy that attempted to fill your prescription.
3. The date you attempted to fill your prescription.
4. If you ask for an exception, your prescriber will need to provide your drug plan
with a statement explaining why you need the off-formulary or non-preferred drug
or why a coverage rule should not apply to you.
Your Medicare drug plan will provide you with a written decision. If coverage is not
approved, the plan’s notice will explain why coverage was denied and how to request
an appeal if you disagree with the plan’s decision.
Refer to your plan materials or call 1-800-Medicare for more information.
Form CMS -10147
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