DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
[Part D Plan Logo]
YOUR ACCESS TO CERTAIN PART D DRUGS WILL NOT BE LIMITED
Date: [insert date]
Enrollee’s Name: [insert name] Member Number: [insert member ID]
On [Insert date of initial notice], we sent you a notice that we planned to limit your access to prescription [insert as appropriate: {opioids} or {benzodiazepines} or {opioids and benzodiazepines}] through our drug management program.
After further review, we have decided that your access to these medications will NOT be limited under the drug management program. There are no changes to the way these medications are covered for you under our plan rules.
[Insert this section for Low Income Subsidy (LIS) beneficiaries:]
{As of the date of this notice, you’re eligible to use the monthly Medicare Special Enrollment period to enroll in a standalone Part D plan because you receive Extra Help with your prescription drug costs. You can also change plans during other limited situations, such as if you move out of the plan’s service area or you lose or have a change in your Extra Help. You can also change plans during the Annual Enrollment Period which occurs every year from October 15 – December 7.}
If you have questions about this notice or our drug management program to help enrollees use prescription opioid medications safely, contact us at:
[Plan Name] Toll Free: [Insert phone number] TTY users: [Insert TTY]
[Insert call center hours of operation]
[Insert plan website]
[Insert plan mailing address]
[If the plan has a dedicated line (toll free), staff person, web portal, etc. for its DMP, that information may be included in this section, as applicable.]
If you have questions about your opioid pain medication or other prescription drugs you are taking, speak with your prescriber.
______________________________________________
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 0938-1465. This information collection is necessary for informing potentially at-risk beneficiaries that such beneficiaries’ access to frequently abused drugs will not be restricted to a selected prescriber, network pharmacy(ies), and/or through a beneficiary-specific point-of-sale claim edit, in accordance with CMS requirements for how drug management programs address overutilization of frequently abused drugs. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory (42 CFR 423.153(f)(7)), and personal identifiable information is not being collected electronically. 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. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact PartD_OM@cms.hhs.gov.
Form CMS-10874 OMB Approval No. 0938-1465 (Expires 11/30/2027)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CM-MDBG |
| File Modified | 0000-00-00 |
| File Created | 2025-09-19 |