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MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 09380990 FOR USE ON OR AFTER APRIL 1, 2011Important Notice From Insert Name of Entity About Your Prescription Drug Coverage and

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What is model individual non-creditable coverage?

Model individual non-creditable coverage is a disclosure form that provides information about the creditability of prescription drug coverage offered by an entity.

Who is required to file model individual non-creditable coverage?

Entities offering prescription drug coverage to Medicare-eligible individuals are required to file model individual non-creditable coverage.

How to fill out model individual non-creditable coverage?

Model individual non-creditable coverage can be filled out online or submitted through mail following the instructions provided by the Centers for Medicare & Medicaid Services (CMS).

What is the purpose of model individual non-creditable coverage?

The purpose of model individual non-creditable coverage is to inform Medicare-eligible individuals whether their prescription drug coverage is creditable or non-creditable.

What information must be reported on model individual non-creditable coverage?

Information such as the plan sponsor's name, prescription drug coverage type, and whether the coverage is creditable or non-creditable must be reported on model individual non-creditable coverage.