Required “Your Rights” notice for your Part D enrollees
CMS requires you, as a Network Pharmacy Provider, to distribute a Medicare Prescription Drug Coverage and Your Rights notice to your Part D enrollees when their prescription cannot be covered/filled under the Medicare Part D benefit at the point-of-sale.
The notice must be provided to the enrollee if your pharmacy receives a transaction response (rejected or paid) indicating the claim is not covered by Part D.
About the notice
The Your Rights notice instructs enrollees about their right to contact their Part D plan, how to obtain a coverage determination or request an exception if they disagree with the information provided by the pharmacist.
This notice fulfills the requirements at 42 CFR §423.562(a)(3) and §423.128(b)(7)(iii).
Notice requirements for pharmacies
- The 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.
- Your logo is not required. Pharmacies may, however, place their logo in the space above the optional fields for the enrollee’s name and the drug and prescription number.
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