Every year, employers must disclose if the employer-sponsored prescription drug plan is considered creditable or non-creditable coverage to the Centers for Medicare and Medicaid Services (CMS). Note: If you do not have any Medicare-eligible individuals covered by your medical/prescription drug plan as of the start of your plan year, you do not need to complete this form.

This disclosure is required within 60 days of the start of the medical plan year and only takes a few minutes to complete online. For your medical plan(s) that renew January 1, the disclosure must be submitted by February 29, 2024. Instructions are provided below, and you can also access detailed information/instructions on the CMS website. 

• Enter Entity/Plan Sponsor Information – Enter company name, tax ID, address and phone number

• For Coverage Type, select "GROUP HEALTH PLAN: Employer Sponsored Plan"

• For Creditable/Non-Creditable Offer, select “All Options Offered are Creditable” (or the appropriate response if you offer any plans with non-creditable prescription drug coverage)

• Plan Year Beginning Date: Enter first day of plan year; Plan Year Ending Date: Enter last day of plan year

• Total number of Medicare Part D Eligible Individuals expected to be covered under these Option(s) as of the Plan Year Beginning Date stated above –Enter estimated number of covered individuals age 65+ or under age 65 and Medicare-eligible due to disability; include eligible employees, dependents, retirees, and COBRA participants

• Out of the estimated number of those Medicare D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan – Enter estimated number of retirees (enter “0” if retiree coverage not offered)

• Date that the Annual Creditable Coverage Disclosure to Part D Eligible Individuals requirement was provided by the Entity – Enter date the latest disclosure was sent (due annually by 10/15) 

• Has your Creditable Coverage Status (Creditable, Non-Creditable Options Offered) changed from the last plan year? Check “No” (or appropriate response if status changed)

• Review agreement & enter your name, title, email address and date.

• Click on “Review and Submit” and follow remaining instructions to either Go Back & Edit, Print or Submit.

• Once submitted, you should receive a screen message that says “Success! Your form has been successfully submitted.”  

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