CMS-10874 Model Sponsor Information Transfer Memorandum

Model Part D Drug Management Program Sponsor Information Transfer Memorandum
Instructions: This memorandum could be used by a former sponsor to respond to a new sponsor
that has requested case management information about a potential at-risk beneficiary or at-risk
beneficiary who disenrolled from the former sponsor’s plan. It is intended to convey information
about the former sponsor’s findings about the beneficiary’s prior opioid and/or benzodiazepine
utilization and/or history of opioid-related overdose, and to provide the new sponsor with the
records and actions generated by the former sponsor’s review of the beneficiary under its Drug
Management Program. This is a model document; therefore, its use is optional and sponsors
may modify content or use an alternate letter in order to transfer the requested information.

DATE:
TO: New Sponsor
FROM: Former Sponsor
RE: Drug Management Program Information for
______________________________________________________________________________
The purpose of this memo is to highlight certain information that
is providing in response to a request that we received on from to transfer case management information and associated records for
from our Drug Management Program. received notice from
on through MARx that had an Active
CARA Status when they disenrolled from and enrolled in effective .
had the status of [Select one as applicable:
under Drug Management Program. [Select
one, as applicable: on
.
_______________________________________________
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 collection is 0938-TBD. If you have any suggestions for
improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.
CMS does not discriminate in its programs and activities: To request this form in an accessible format
(e.g., Braille, Large Print, Audio CD) contact your Medicare Drug Plan. If you need assistance contacting
your plan, call: 1-800-MEDICARE.
Form CMS-10874

OMB Approval No. 0938-TBD (Expires xx/xx/xxxx)

The limitation(s) that [Select one, as applicable:
] on access to coverage for [Select as applicable:
] is:
[[Select if applicable: a Prescriber Limitation for [Select as applicable:
.] The selected prescriber is and their individual NPI is
. The contact information we have for the prescriber is .]]
[[Select if applicable: a Pharmacy Limitation for [Select as applicable:
. The selected pharmacy is and its organizational NPI is
. The address we have for the pharmacy is .]]
[[Select if applicable: a Beneficiary-specific POS claim edit such that [Select as applicable: Only
is covered every days.]]
More detail is included in the documents accompanying this memorandum, which contain copies
of the applicable beneficiary notice(s) and of the records from the case management that was
conducted under Drug Management Program upon which the decision to
implement the coverage limitation(s) was based. Specifically, the following minimum necessary
records are permitted to be transferred under applicable law and include:
[List the records that are included. Examples of records that could be included are:
a) notation whether the beneficiary met the minimum or supplemental OMS criteria;
b) copies of medical records;
c) beneficiary drug utilization history;
d) correspondence with prescribers and the beneficiary;
e) notes documenting telephone conversations; and
f) documentation of the decision arrived at through case management.
If you have any questions concerning this memorandum, please contact at
<Contact Information.>

[Insert beneficiary identifying information]

Form CMS-10874

OMB Approval No. 0938-TBD (Expires xx/xx/xxxx)

</pre><Table class="table"><tr><Td>File Type</td><td>application/pdf</td></tr><tr><Td>File Title</td><td>Model Part D Drug Management Program Sponsor Information Transfer Memorandum</td></tr><tr><Td>Author</td><td>CM/MGBG/DPDP-DCOP</td></tr><tr><Td>File Modified</td><td>2023-11-16</td></tr><tr><Td>File Created</td><td>2023-11-16</td></tr></table></div></div></div><hr>
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