CMS-10260-PDP's Annual Notice of Change & Evidence of Coverage for Presc

Annual Notice of Change & Evidence of 
Coverage for Prescription Drug Plans 

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 0938-1051. The time required to complete this information collection is
estimated to average
( 30 min) per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. 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.

[Insert date]
[Plans may add a greeting (e.g., Dear Member, Dear Mrs. [insert name]).]
Here are [insert as applicable: two OR three] documents with important information for you.
1. Please start by reading the Notice of Changes for 2010. It gives you a summary of
changes to your benefits and costs for next year. These changes will take effect on January
1, 2010.
• Please take a moment very soon to look through this summary and see how the changes
might affect you.
• If you decide to stay with [insert plan name] for 2010 – you do not have to tell us or fill
out any paperwork. You will automatically remain enrolled as a member of [insert plan
name]).
• If you decide to leave [insert plan name], you can keep Original Medicare either with or
without a new Medicare prescription drug plan or you can switch to a Medicare
Advantage plan. You can make these changes from November 15 through December 31
each year.
2. We’re including a copy of next year’s Evidence of Coverage. It’s the legal, detailed
description of your benefits and costs for 2010 if you stay enrolled as a member of
[insert plan name]. It also explains your rights and rules you need to follow when using
your coverage for medical care and prescription drugs. Please look through this
document so you know what’s in it, then keep it handy for reference.
3. We’re also including a copy of the [insert plan name] List of Covered Drugs
(Formulary), (“Drug List” for short) effective in January 2010.
If you have questions, we’re here to help. Please call Member Services at [insert phone
number] (TTY/TDD only, call [insert TTY/TDD number]). Hours are [insert days and hours
of operation] and calls to these numbers are [insert as applicable: free OR not free]. You can
also visit our website, ([insert URL]).
We value your membership and hope to continue to serve you next year.
[Plans may add a closing (e.g., Sincerely) and signature.]

[Insert plan name] Notice of Changes for 2010
If you remain enrolled in [insert plan name]
for 2010, there will be some changes next
year to your benefits and what you pay
[Plans may modify this introductory paragraph to tailor to its needs, as long as the paragraph is
kept brief.]
You are currently enrolled as a member of [insert plan name]. We are pleased to be providing your
prescription drug coverage. [Plans that are consolidating, changing plan name or rolling over
membership, as approved by CMS, in 2010, insert: (1) if changing the plan name, or consolidating
other plans into the plan in which the beneficiary is enrolled – “We also want to let you know that
we have changed our plan name from [insert previous plan name] to [insert new plan name] for
the upcoming year.” (2) if the beneficiary is being passively enrolled into another plan due to a
consolidation or termination – “As we have explained, if you do not choose another plan, you will
be enrolled in the [insert plan name]. This notice describes changes in benefits from [insert
previous plan name] to the [insert plan name] next year.”]
We’re sending you this Notice of Changes to tell you how your benefits and costs as a member
of [insert plan name] will change next year from your current benefits. The changes take effect
on January 1, 2010. Medicare has approved these changes.
What should you do?
We want you to know what’s ahead for next year, so please read this document very soon to see
how the changes in benefits and costs will affect you if you stay enrolled in [insert plan name]
for 2010.
To decide what’s best for you, compare this information we’re sending with the benefits and costs
of other Medicare Advantage plans in your area and with the Original Medicare Plan. We hope to
keep you as a member of [insert plan name]. But if you want to make a change for 2010, see
“When can you change” in Section [X] for time periods when you can make a change.

WeÕre here to help!
We are available for phone calls [insert
days and hours of operation]. Calls to these
numbers are [insert if applicable: not] free.
[Insert phone number]
[Insert TTY/TDD number] TTY/TDD only
[Plans may insert additional numbers, e.g,
the planÕsfax number or a number for
callers who speak Spanish.]

Website: [insert URL]
Do you need large print or another
format?
To get this material in other formats,
including large type, Braille, and
translations into other languages, call
Member Services.

[Note: If section is deleted, update table of contents to reflect this change.]
Section 1: Important things to know .............................................................. [x]
Your plan name is changing for the upcoming year ................................. [x]
This Notice of Changes is only a summary (see your Evidence
of Coverage for the details) ...................................................................... [x]
There are programs to help people with limited resources pay
for their prescription drugs........................................................................ [x]
Section 2: Changes to your monthly premium ............................................. [x]
Section 3: PART D PRESCRIPTION DRUGS:
Changes to your benefits and what you pay ............................................ [x]
Changes to your benefits ........................................................................... [x]
Changes to what you pay .......................................................................... [x]
What if changes for 2010 affect drugs you are taking now? .................... [x]
Section 4: Do you want to stay in the plan or make a
change?.................................................................................................. [x]
Do you want to stay with [insert plan name] ...........................................[x]
Do you want to make a change? ............................................................... [x]
Section 5: Do you need some help? Would you like more information? .... [x]
We have information and answers for you ............................................... [x]
You can get help and information from your State Health Insurance
Assistance Program .................................................................................. [x]
You can get help and information from Medicare .................................... [x]

Notice of Changes in [insert plan name] for 2010

1

Section 1. Important things to know
[Insert first subsection if plan is either changing the plan name for the upcoming year or LIS
beneficiaries are being reassigned:
Your plan name is changing for the upcoming year
Plans that are consolidating, changing plan name, or rolling over membership, insert: (1) if
changing the plan name, or consolidating other plans into the plan in which the beneficiary is
enrolled—We want to let you know that we have changed our plan name from [insert previous
plan name] to [insert new plan name] for the upcoming year. Our phone numbers and address will
remain the same; (2) if the beneficiary is being passively enrolled into another plan due to a
consolidation or termination – “As we have explained, if you do not choose another plan, or
choose to enroll in the Original Medicare Plan, you will be enrolled in the [insert plan name].
This notice describes changes in benefits from [insert previous plan name] to the [insert plan
name] next year.”]
[PDPs that will lose certain LIS beneficiaries to re-assignment to a plan within the same PDP
sponsoring organization, do not insert the previous sentence and insert the following in the ANOC
for members affected by re-assignment: You are currently enrolled in [insert 2009 plan name].
Because the premium for the plan you have now is increasing in 2010, you will be moved to
[insert 2010 plan name], where you won’t have to pay any monthly premium in 2010. You can
choose to stay with [insert 2009 plan name], the plan you have now, but you will have to pay a
monthly premium. If you want to stay with the plan you have now, you must call Member
Services to tell us, otherwise you will automatically be enrolled in the new plan.
Please note that this Notice of Changes describes the changes in benefits from 2009 to 2010 for the
new plan, [insert 2010 plan name]. It does not compare the benefits you have under your current
plan, [insert 2009 plan name], with the benefits you would have under the new plan, [insert 2010
plan name].]]
This Notice of Changes is only a summary (see your
Evidence of Coverage for the details)
This Notice of Changes gives you a summary of the changes in your benefits and what you will
pay for these services in 2010.
•

To get the details, you can look in the 2010 Evidence of Coverage for [insert plan name].
The Evidence of Coverage is the legal, detailed description of your benefits and costs for
2010. It explains your rights and the rules you need to follow to get your prescription drugs.
(We have included a copy of the Evidence of Coverage in the same envelope with this
Notice of Changes. If you do not have this copy, call Member Services.)

•

If you have questions or need more information, you can always call Member Services
(phone numbers are on the cover of this notice).

Notice of Changes in [insert plan name] for 2010

2

There are programs to help people with limited
resources pay for their prescription drugs
You might qualify to get help in paying for your drugs. There are [insert as applicable: one OR
two] basic kinds of help:
•

“Extra Help” from Medicare. This program is also called the “low-income subsidy” or
LIS. People whose yearly income and resources are below certain limits can qualify for
this help. See Section III of the new Medicare & You 2010 or call 1-800-MEDICARE (1800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for
free, 24 hours a day, 7 days a week.

•

[Plans without an SPAP in their state(s), should delete this bullet.] Help from your state’s
pharmaceutical assistance program. Many states have State Pharmaceutical Assistance
Programs (SPAPs) that help some people pay for prescription drugs based on financial
need, age, or medical condition. Each state has different rules. Check with your State
Health Insurance Assistance Program (the name and phone numbers for this organization
are in Chapter 2, Section 3 of your Evidence of Coverage).

What if you are currently getting help to pay for your drugs?
[Delete this section if this is your LIS ANOC.]
If you already get help paying for your drugs, some of the information in this Notice of
Changes is not correct for you. Please call Member Services and ask for the Notice of Changes
for people who get extra help paying for drugs.
Section 2. Changes to your monthly premium

Monthly premium

2009 (this year)

2010 (next year)

[insert 2009
premium amount]

[insert 2010
premium amount]

Exception: If you are required to pay a late enrollment penalty (because you did not join a
Medicare drug plan when you first became eligible), your monthly premium for 2010 will be
[insert 2010 premium amount] plus the amount of your late enrollment penalty. For more
about this penalty, see Chapter 4 of your Evidence of Coverage.

Notice of Changes in [insert plan name] for 2010

3

Section 3. Part D Prescription Drugs: Changes to your
benefits and what you pay
[If there are no changes in benefits or in cost-sharing, replace remainder of Section 3 with:
[Insert plan name] has a “List of Covered Drugs (Formulary)” – or “Drug List” for short. It tells
which Part D prescription drugs are covered by the plan. (Chapter 3, Section 1.1 of your
Evidence of Coverage explains about Part D drugs.)
The drugs included on our Drug List and the amount you will pay for covered drugs will be the
same in 2010 as in 2009. However, we are allowed to make changes to the plan’s Drug List from
time to time throughout the year, with approval from Medicare.]
Changes to your benefits
[Insert plan name] has a “List of Covered Drugs (Formulary)” – or “Drug List” for short. It tells
which Part D prescription drugs are covered by the plan. (Chapter 3, Section 1.1 of your
Evidence of Coverage explains about Part D drugs.)
[If there are no changes in benefits but changes in cost-sharing, replace text below with: The
drugs included on our Drug List will be exactly the same in 2010 as it is in 2009. However, there
are some changes in what you will pay for these covered drugs. In addition, we are allowed to
make changes to the plan’s Drug List from time to time throughout the year, with approval from
Medicare.]
We may make changes to the plan’s Drug List from time to time throughout the year. In
addition, there are a number of changes to the Drug List that will take effect on January 1,
2010. Changes to the plan’s Drug List have been approved by Medicare.
•

[Insert if applicable: We have [insert as applicable: added some new drugs to the
list and removed others OR added some new drugs to the list OR removed some
drugs from the list]. [Insert if applicable: We have added some new drugs that
became available.] [Insert if applicable: We have replaced some brand-name drugs
with new generic drugs.] [Insert if applicable: We have replaced some expensive
drugs with less costly drugs that have been shown to work just as well or better.]
[Insert if applicable: We have removed a few drugs due to safety concerns or because
medical research has shown they are not effective.] [Plans may describe other types of
changes to the formulary here.]

•

[Insert if applicable: We have [insert as applicable: added some new restrictions to
certain drugs, and reduced the restrictions on others OR added some new
restrictions to certain drugs OR reduced the restrictions on some drugs]. [Plans may
edit the next two sentences to delete references to types of utilization management that
they do not use.] Restrictions can include a requirement to get plan approval in advance

Notice of Changes in [insert plan name] for 2010

4

or to try a different drug first to see how well it works. Restrictions can also include
limits on quantity of the drug.]
Please check to see if any of these changes to drug coverage affect the drugs you use.
•

You can look for your drugs on the Drug List we sent with this Notice of Change. [If
including a complete formulary, insert: If you can’t find some of your drugs on this Drug
List, you can call Member Services for help finding your drugs.]

•

[If including an abridged formulary, use the following language: The Drug List we sent
includes many of the drugs that we cover, but it does not include all of our covered drugs.
If you can’t find some of your drugs on this Drug List, you may find them on a complete
Drug List, which includes all the drugs we cover. You can get the complete Drug List by
calling Member Services or visiting our website ([insert URL]).]

Changes to what you pay
[If there are no changes in cost-sharing, replace text and table below with: The [insert as
applicable: copayment OR coinsurance] amount you pay for covered drugs will be exactly the
same in 2010 as it is in 2009.]
[Plans should edit or add to the information below to describe any changes in cost group
structure or types of drugs in each cost group, as necessary.]
The chart below summarizes changes to what you will pay as your share of the cost of covered
prescription drugs. These changes affect Part D prescription drugs only.
•

[Plans without drug cost groups, replace this bullet with: Medicare allows us to change
what you pay for a drug only once a year. The changes shown below will take effect on
January 1, 2010, and stay the same for the entire plan year.] Every drug on the plan’s
Drug List is in one of [insert number of cost groups] Cost Groups. Medicare allows us to
change what you pay for a drug in each Cost Group only once a year. The changes
shown below will take effect on January 1, 2010, and stay the same for the entire plan
year.

•

[Plans without drug cost groups and plans with no change in cost group assignment,
delete this bullet.] Besides the changes to [insert as applicable: copayment OR
coinsurance] you see below, there is another change that could affect what you pay for
your drugs next year. We have moved some of the drugs on the Drug List to a
different Cost Group. Some drugs will be in a lower Cost Group, others will be in a
higher Cost Group. To see if any of your drugs have been moved to a different Cost
Group, look them up on the Drug List.

Notice of Changes in [insert plan name] for 2010

5

[Plans should list all changes to cost-sharing in the table below. Plans may add or delete rows as
necessary. Plans without drug cost groups may revise the table as appropriate.]

Drugs in Cost Group [x]
([insert short description of cost
group (e.g., generic drugs)])
For a one-month (30 day) supply
of a drug in Cost Group [x] that is
filled at a network pharmacy

Drugs in Cost Group [x]
([insert short description of cost
group (e.g., generic drugs)])
For a one-month (30 day) supply
of a drug in Cost Group [x] that
is filled at a network pharmacy

2009 (this year)

2010 (next year)

[insert 2009 costsharing:

[insert 2010 costsharing:

For copayments:
You pay $xx per
prescription.

For copayments:
You pay $xx per
prescription.

For coinsurance:
You pay xx% of the
total cost.]

For coinsurance:
You pay xx% of
the total cost.]

[insert 2009 costsharing:

[insert 2010 costsharing:

For copayments:
You pay $xx per
prescription.

For copayments:
You pay $xx per
prescription.

For coinsurance:
You pay xx% of
the total cost.]

For coinsurance:
You pay xx% of
the total cost.]

What if changes for 2010 affect drugs you are taking now?
[Delete if plan is not removing any drugs from formulary:] What if a drug you are taking now
is not on the Drug List for 2010? [Delete if plan is not changing the cost group assignment for
any drugs on the formulary or if the plan does not use cost groups:] What if it has been moved
to a higher Cost Group? [Delete if plan is not adding restrictions to any drug on the
formulary:] What if a new restriction has been added to the coverage for this drug? If you are
in any of these situations, here’s what you can do:

• [Plans may omit this bullet if they allow current members to request formulary
exceptions in advance for the following year:] In some situations, the plan will cover a
one-time, temporary supply of your drug when your current supply runs out. This
temporary supply will be for a maximum of 30 days, or less if your prescription is written

Notice of Changes in [insert plan name] for 2010

6

for fewer days. Chapter 3, Section 6.2 explains when you can get a temporary supply

and how to ask for one.
[Plans may omit this sentence if they allow current members to request formulary exceptions in
advance for the following year:] Meanwhile, you and your doctor will need to decide what to do
before your temporary supply of the drug runs out.
•

Perhaps you can find a different drug covered by the plan that might work just as well
for you. You can call Member Services to ask for a list of covered drugs that treat the
same medical condition. This list can help your doctor or other prescriber to find a
covered drug that might work for you.

•

You and your doctor can ask the plan to make an exception for you and cover the
drug. [Plans may omit the following sentence if they allow current members to receive a
temporary supply instead:] You can ask for an exception in advance for next year and we
will give you an answer to your request before the change takes effect. To learn what you
must do to ask for an exception, see the Evidence of Coverage that was included in the
mailing with this Notice of Changes. Look for Chapter 7 (What to do if you have a
problem or complaint).

[Plans may include additional information about processes for transitioning current enrollees to
formulary drugs when your formulary changes relative to the previous plan year.]
Section 4. Do you want to stay in the plan or make a
change?
Do you want to stay with [insert plan name]?
If you want to keep your membership in [insert plan name] for 2010, it’s easy. You don’t
need to tell us or fill out any paperwork. You will automatically remain enrolled as a
member.
Do you want to make a change?
If you decide to leave [insert plan name], you can switch to a different Medicare prescription
drug plan, Original Medicare without a separate Medicare prescription drug plan, or a Medicare
Advantage plan.
If you want to change to a different plan, there are many choices. [Insert if applicable: As a
reminder, [insert plan name] offers other Medicare prescription drug plans in addition to the plan
you are now enrolled in. These other plans may differ in coverage, monthly premiums, and cost
sharing amounts.]
When can you change?
•

During the yearly enrollment period (called the “annual coordinated election
period”) from November 15 through December 31, 2009, you can change to another

Notice of Changes in [insert plan name] for 2010

7

Medicare prescription drug plan, Original Medicare without a separate Medicare
prescription drug plan, or a Medicare Advantage plan. Your new coverage will begin on
January 1, 2010.
Are these the only times of year to choose a different plan?
For most people, yes. Certain individuals, such as those with Medicaid, those who get Extra Help
paying for their drugs, or those who move out of the geographic service area, can make changes
at other times. For more information, see Chapter 8, Section 2.3 of the Evidence of Coverage.
How do you make a change?
See Chapter 8 of the enclosed Evidence of Coverage document. It tells what you need to do to
make a change from [insert plan name] to another plan.
Things to check on before you make a change
• Are you a member of an employer or retiree group? If you are, please check with the
benefits administrator of your employer retiree group before you switch to another way of
getting medical care.
• [Plans in state(s) without an SPAP, delete this bullet.] Are you getting help with paying
for your drugs from a State Pharmaceutical Assistance Program (SPAP)? If you are,
please check with this program before switching to another prescription drug plan. The
phone number for your State Pharmaceutical Assistance Program is listed in Chapter 2,
Section 7 of the Evidence of Coverage.
Section 5. Do you need some help? Would you like more
information?
We have information and answers for you
To learn more, read the information we sent in the same package with this Notice of Changes. This
includes a copy of the Evidence of Coverage and of the List of Covered Drugs (Formulary).
If you have any questions, we are here to help. Please call us at [insert plan name] Member
Services. We are available for phone calls [insert days and hours of operation]. Calls to these
numbers are free: [insert phone number] (TTY/TDD only, call [insert TTY/TDD number]).
You can get help and information from your State Health
Insurance Assistance Program
[Organizations offering plans in multiple states: Revise this section to use the generic name
(“State Health Insurance Assistance Program”) when necessary, and include a list of names,
phone numbers, and addresses for all SHIPs in your service area. Plans have the option of

Notice of Changes in [insert plan name] for 2010

8

including a separate exhibit to list the SHIPs in all states, or in all states in which the plan is filed,
and should make reference to that exhibit below.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. In [insert state name], the State Health Insurance Assistance Program is
called [insert state-specific SHIP name].
[Insert state-specific SHIP name] is independent (not connected with any insurance company
or health plan). [Insert state-specific SHIP name] counselors can help you with your Medicare
questions or problems. They can help you understand your Medicare plan choices and answer
questions about switching plans. You can call [insert state-specific SHIP name] at [insert
phone number(s), including TTY/TDD number if available].
You can get help and information from Medicare
Here are three ways to get information directly from Medicare:
•

Call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.

•

Visit the Medicare website (www.medicare.gov).

•

Read Medicare & You 2010. Every year in October, this booklet is mailed to people with
Medicare. It has a summary of Medicare benefits, rights and protections, and answers to
the most frequently asked questions about Medicare. If you don’t have a copy of this
booklet, you can get it at the Medicare website (www.medicare.gov) or by calling 1-800MEDICARE (1-800-633-4227).

January 1 – December 31, 2010

Evidence of Coverage
This booklet is an important legal document for you to
keep and use as a reference during 2010. It explains:
The details of your Medicare prescription drug
coverage
How to get the drugs you need

[Include plan contact information on the cover.]

2010 Evidence of Coverage for [insert plan name]
Table of Contents

Table of Contents
This list of chapters and page numbers is just your starting point. For more help
in finding information you need, go to the first page of a chapter. You will find a
detailed list of topics at the beginning of each chapter.

Chapter 1.

Getting started as a member of [insert plan name] ...........................[XX]
Tells what it means to be in a Medicare prescription drug plan and how to use
this booklet. Tells about materials we will send you, your plan premium, your
plan membership card, and keeping your membership record up to date.

Chapter 2.

Important phone numbers and resources ..........................................[XX]
Tells you how to get in touch with our plan ([insert plan name]) and with
other organizations including Medicare, the State Health Insurance Assistance
Program, the Quality Improvement Organization, Social Security, Medicaid
(the state health insurance program for people with low incomes), programs
that help people pay for their prescription drugs, and the Railroad Retirement
Board.

Chapter 3.

Using the plan’s coverage for your Part D prescription drugs.........[XX]
Explains rules you need to follow when you get your Part D drugs. Tells how
to use the plan’s List of Covered Drugs (Formulary) to find out which drugs
are covered. Tells which kinds of drugs are not covered. Explains several
kinds of restrictions that apply to your coverage for certain drugs. Explains
where to get your prescriptions filled. Tells about the plan’s programs for drug
safety and managing medications.

Chapter 4.

What you pay for your Part D prescription drugs ..............................[XX]
Tells about the [insert number of stages] stages of drug coverage ([delete
any stages that are not applicable] Deductible Stage, Initial Coverage
Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these
stages affect what you pay for your drugs. [Plans without drug cost groups,
delete the following sentence.] Explains the [insert number of cost groups]
Cost Groups for your Part D drugs and tells what you must pay ([insert as
applicable: copayment OR coinsurance] as your share of the cost for a drug
in each Cost Group. Tells about the late enrollment penalty.

Chapter 5.

Asking the plan to pay its share of the cost for a drug .....................[XX]

2010 Evidence of Coverage for [insert plan name]
Table of Contents

Tells when and how to send a bill to us when you want to ask us to pay you
back for our share of the cost for your drugs.
Chapter 6.

Your rights and responsibilities ..........................................................[XX]
Explains the rights and responsibilities you have as a member of our plan. Tells
what you can do if you think your rights are not being respected.

Chapter 7.

What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) ............................................. [XX]
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.

Chapter 8.

•

Explains how to ask for coverage decisions and make appeals if you are
having trouble getting the prescription drugs you think are covered by our
plan. This includes asking us to make exceptions to the rules and/or extra
restrictions on your coverage.

•

Explains how to make complaints about quality of care, waiting times,
customer service, and other concerns.

Ending your membership in the plan..................................................[XX]
Tells when and how you can end your membership in the plan. Explains
situations in which our plan is required to end your membership.

Chapter 9.

Legal notices.........................................................................................[XX]
Includes notices about governing law and about nondiscrimination.

Chapter 10. Definitions of important words............................................................[XX]
Explain key terms used in this booklet.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

1

CHAPTER 1: Getting started as a member of [insert plan name]
SECTION 1. Introduction
1.1

What is this Evidence of Coverage booklet about? .................................................. [xx]

1.2

What does this Chapter tell you? .............................................................................. [xx]

1.3

What if you are new to [insert plan name]? .............................................................[xx]

1.4

Legal information about Evidence of Coverage ....................................................... [xx]

SECTION 2. What makes you eligible to be a plan member?
2.1 Your two eligibility requirements ............................................................................[xx]
2.2

What are Medicare Part A and Medicare Part B? ..................................................... [xx]

2.3

Here is the geographic service area for [insert plan name]......................................[xx]

SECTION 3. What other materials will you get from us?
3.1

Your plan membership card – use it to get all covered care and drugs .................... [xx]

3.2

The Pharmacy Directory: your guide to pharmacies in our network ......................[xx]

3.3

The plan’s List of Covered Drugs (Formulary) .......................................................[xx]

3.4

Monthly reports with a summary of payments for your prescription drugs ............. [xx]

SECTION 4. Your monthly premium for [insert plan name]
4.1

How much is your plan premium? ............................................................................ [xx]

4.2

There are [insert number of payment options] ways you can pay your plan
premium .................................................................................................................. [xx]

4.3

Can we change your monthly plan premium during the year? ................................. [xx]

SECTION 5. Please keep your plan membership record up to date
5.1

How to help make sure that we have accurate information about you ..................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

SECTION 1

Chapter 1
Section 1.1

2

Introduction
What is the Evidence of Coverage
booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare prescription drug
coverage through our plan. This booklet explains your rights and responsibilities, what is
covered, and what you pay as a member of the plan.
•

You are covered by Original Medicare for your health care coverage, and you have
chosen to get your Medicare prescription drug coverage through our plan, [insert plan
name].

In this Evidence of Coverage, the terms “we,” “our,” “the plan,” “our plan,” and “your plan,” all
refer to [insert plan name].
The word “coverage” and “covered drugs” refers to the prescription drug coverage available
to you as a member of [insert plan name].

Chapter 1
Section 1.2

What does this Chapter tell you?

Look through Chapter 1 of Evidence of Coverage to learn:
•

What makes you eligible to be a plan member?

•

What materials will you get from us?

•

What your plan premium is and how you can pay it?

•

How to keep the information in your membership record up to date.

Chapter 1
Section 1.3

What if you are new to [insert plan
name]?

If you are a new member, then it’s important for you to learn how the plan operates – what the
rules are and what coverage is available to you. We encourage you to set aside some time to look
through this Evidence of Coverage booklet.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

3

If you are confused or concerned or just have a question, please contact our plan’s Member
Services (contact information is on the cover of this booklet).

Chapter 1
Section 1.4

Legal information about Evidence of
Coverage

It’s part of our contract with you
This Evidence of Coverage is part of our contract with you about how [insert plan name] covers
your care. Other parts of this contract include your enrollment form, the List of Covered Drugs
(Formulary), and any notices you receive from [insert plan name] about changes or extra
conditions that can affect your coverage. These notices are sometimes called “riders” or
“amendments.”
The contract is in effect for months in which you are enrolled in [insert plan name] between
January 1, 2010 to December 31, 2010.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve [insert plan name] each
year. You can continue to get Medicare coverage as a member of our plan only as long as we
choose to continue to offer the plan for the year in question and the Centers for Medicare &
Medicaid Services renews its approval of the [insert plan name] plan.

SECTION 2

Chapter 1
Section 2.1

What makes you eligible to be a
plan member?

Your two eligibility requirements

You are eligible for membership in our plan as long as:
•

You live in our geographic service area (section 2.3 below describes our service area)

•

-- and -- you are entitled to Medicare Part A or you are enrolled in Medicare Part B (or
you have both Part A and Part B)

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

Chapter 1
Section 2.2

4

What are Medicare Part A and Medicare
Part B?

When you originally signed up for Medicare, you received information about how to get
Medicare Part A and Medicare Part B. Remember:
•

Medicare Part A generally covers services furnished by institutional providers such as
hospitals, skilled nursing facilities or home health agencies.

•

Medicare Part B is for most other medical services, such as physician’s services and other
outpatient services.

To learn whether you have Medicare Part A and Part B, you can look on your red, white, and
blue Medicare card. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227)
24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Chapter 1
Section 2.3

Here is the geographic service area for
[insert plan name]

Although Medicare is a Federal program, [insert plan name] is available only to individuals who
live in our geographic service area. To join our plan, you must live in this service area. To stay a
member of our plan, you [if a “continuation area” is offered under 42 C.F.R. 422.54, insert
“generally” here, and add a sentence describing the continuation area] must keep living in this
service area. The service area is described [insert as appropriate: below OR in an appendix to
this Evidence of Coverage.]
[Insert plan services area here or within an appendix. Plans may include references to
territories as appropriate. Use county name only if approved for entire county. For partially
approved counties, use county name plus zip code. Examples:
Our service area includes these states: [insert states]
Our service area includes these counties in [insert state]: [insert counties]
Our service area includes these parts of counties in [insert state]: [insert county], the following
zip codes only [insert zip codes]]
If you are not sure whether you live in the service area, or if you plan to move out of the service
area, please contact Member Services.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

SECTION 3

Chapter 1
Section 3.1

5

What other materials will you get from
us?

Your plan membership card – Use it to get
all covered prescription drugs

While you are a member of our plan, you must use our membership card for prescription drugs
you get at network pharmacies. Here’s a sample membership card to show you what yours will
look like:
[Insert picture of front and back of member ID card. Mark it as a sample card (for example, by
superimposing the word “sample” on the image of the card.]
Please carry your card with you at all times and remember to show your card when you get
covered drugs. If your plan membership card is damaged, lost, or stolen, call Member Services
right away and we will send you a new card.
You may need to use your red, white, and blue Medicare card to get covered medical care and
services under Original Medicare.

Chapter 1
Section 3.2

The Pharmacy Directory: your guide to
pharmacies in our network

What are “network pharmacies”?
Our Pharmacy Directory gives you a complete list of our network pharmacies – that means all of
the pharmacies that have agreed to fill covered prescriptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Pharmacy Directory to find the network pharmacy you want to use. [Plans may
add detail describing additional information included in the pharmacy directory.] This is
important because, with few exceptions, you must get your prescriptions filled at one of our
network pharmacies if you want our plan to cover (help you pay for) them.
We will send you a complete Pharmacy Directory at least once every three years. Every year
that you don’t get a new Pharmacy Directory, we’ll send you a booklet that shows changes to the
directory.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

6

If you don’t have the Pharmacy Directory, you can get a copy from Member Services (phone
numbers are on the front cover). At any time, you can call Member Services to get up-to-date
information about changes in the pharmacy network. You can also find this information on our
website at [insert URL]. [Plans may add detail describing additional information about network
pharmacies available from Member Services or on the website.]

Chapter 1
Section 3.3

The plan’s List of Covered Drugs
(Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells
which Part D prescription drugs are covered by [insert plan name]. The drugs on this list are
selected by the plan with the help of a team of doctors and pharmacists. The list must meet
requirements set by Medicare. Medicare has approved the [insert plan name] Drug List.
We will send you a copy of the Drug List. To get the most complete and current information
about which drugs are covered, you can visit the plan’s website ([insert URL]) or call Member
Services (phone numbers are on the front cover of this booklet).

Chapter 1
Section 3.4

Reports with a summary of payments
made for your prescription drugs

When you use your prescription drug benefits, we will send a report to help you understand and
keep track of payments for your prescription drugs. This summary report is called the
Explanation of Benefits.
The Explanation of Benefits tells you the total amount you have spent on your prescription drugs
and the total amount we have paid for each of your prescription drugs during the month. Chapter
4 (What you pay for your Part D prescription drugs) gives more information about the
Explanation of Benefits and how it can help you keep track of your drug coverage.
At any time during the year, you can also ask us to give you an Explanation of Benefits
summary. To get a copy, please contact Member Services.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

SECTION 4

Chapter 1
Section 4.1

7

Your monthly premium for [insert plan
name]

How much is your plan premium?

As a member of our plan, you pay a monthly plan premium. [Select one of the following: For
2010, the monthly premium for [insert plan name] is [insert monthly premium amount]. OR The
table below shows the monthly plan premium amount for each region we serve. OR The monthly
premium amount for [insert plan name] is listed in [describe attachment].] [Plans may insert a
list of or table with the state/region and monthly plan premium amount for each area included
within the EOC. Plans may also include premium(s) in an attachment to the EOC.]
[Insert if applicable: If you get your benefits from your current or former employer, or from your
spouse’s current or former employer, call the employer’s benefits administrator for information
about your plan premium.]
In some situations, your plan premium could be less than [insert monthly
premium amount]
There are programs to help people with limited resources pay for their drugs. Chapter 2, Section
7 tells more about these programs. If you qualify for one of these programs, enrolling in the
program might make your monthly plan premium lower than [insert monthly premium amount].
[Delete if this is your LIS EOC:] If you are already enrolled and getting help from one of these
programs, some of the payment information in this Evidence of Coverage is wrong for you.
Please call Member Services to get the correct information about what you pay.
In some situations, your plan premium could be more than [insert monthly
premium amount]
Some members are required to pay a late enrollment penalty because they did not join a
Medicare drug plan when they first became eligible or there is a continuous period of 63 days
or more when they didn’t keep their coverage. For these members, the plan’s monthly
premium will be higher. It will be [insert monthly premium amount] plus the amount of their
late enrollment penalty.
If you are required to pay the late enrollment penalty, the amount of your penalty depends on
how long you waited before you enrolled in drug coverage or how many months you were
without drug coverage after you became eligible. Chapter 4, Section 10 explains the late
enrollment penalty.

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

8

Many members are required to pay other Medicare premiums
In addition to paying the monthly plan premium, some plan members will be paying a premium
for Medicare Part A and most plan members will be paying a premium for Medicare Part B.
•

Your copy of Medicare & You 2010 tells about these premiums in the section called
“2010 Medicare Costs.” This explains how the Part B premium differs for people with
different incomes.

•

Everyone with Medicare receives a copy of Medicare & You each year in the fall. Those
new to Medicare receive it within a month after first signing up. You can also download a
copy of Medicare & You 2010 from www.medicare.gov. Or, you can order a printed copy
by phone at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY
users call 1-877-486-2048.

Chapter 1
Section 4.2

There are [insert number of payment
options] ways you can pay your plan
premium

There are [insert number of payment options] ways you can pay your plan premium. [Plans must
indicate how the member can inform the plan of their premium payment option choice and the
procedure for changing that choice.]
Option 1: You can pay by check
Checks should be made out to the plan and sent to the plan. Checks should not be made out to
the Centers for Medicare & Medicaid Services or the U.S. Department of Health and Human
Services (HHS) or the Centers for Medicare & Medicaid Services (CMS) and should not be sent
to these agencies.
[Insert plan specifics regarding premium payment intervals (e.g., monthly, quarterly- please note
that beneficiaries must have the option to pay their premiums monthly), how they can pay by
check, including an address, whether they can drop off a check in person, and by what day the
check must be received (e.g., the 5th of each month). If the plan uses coupon books, explain when
they will receive it and to call Member Services for a new one if they run out or lose it. In
addition, include information if you charge for bounced checks.]
Option 2: [Insert option type]
[If applicable: Insert information about other payment options. Or delete this section.
Include information about all relevant choices (e.g., automatically withdrawn from your bank
account, charged directly to your credit card, charged directly to your debit card). Insert
information on the frequency of automatic deductions (e.g., monthly, quarterly – please note that

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

9

beneficiaries must have the option to pay their premiums monthly), the approximate day of the
month the deduction will be made, and how this can be set up.]
Option [insert number]: You can have the plan premium
taken out of your monthly Social Security check
You can have the plan premium taken out of your monthly Social Security check. Contact
Member Services for more information on how to pay your monthly plan premium this way. We
will be happy to help you set this up.
What to do if you are having trouble paying your plan premium
Your plan premium is due in our office by the [insert day of the month]. If we have not received
your premium by the [insert day of the month], we will send you a notice telling you that your
plan membership will end if we do not receive your premium within [insert length of plan grace
period].
If you are having trouble paying your premium on time, please contact Member Services to see if
we can direct you to programs that will help with your plan premium. If we end your
membership with the plan because of non-payment of premiums, and you don’t currently have
prescription drug coverage then you will not be able to receive Part D coverage until the annual
election period. At this time, you may either join a stand-along prescription drug plan or a health
plan that also provides drug coverage.
If we end your membership due to non-payment of premiums, you will have coverage under
Original Medicare. [Insert if applicable: At the time we end your membership, you may still owe
us for premiums you have not paid. In the future, if you want to enroll again in our plan (or
another plan that we offer), you will need to pay these late premiums before you can enroll.]

Chapter 1
Section 4.3

Can we change your monthly plan
premium during the year?

No. We are not allowed to change the amount we charge for the plan’s monthly plan
premium during the year. If the monthly plan premium changes for next year we will tell
you in October and the change will take effect on January 1.
However, in some cases the part of the premium that you have to pay can change during the year.
This happens if you become eligible for the Extra Help program or if you lose your eligibility for
the Extra Help program during the year. If a member qualifies for Extra Help with their
prescription drug costs, the Extra Help program will pay part of the member’s monthly plan
premium. So a member who becomes eligible for Extra Help during the year would begin to pay
less toward their monthly premium. And a member who loses their eligibility during the year

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

10

will need to start paying their full monthly premium. You can find out more about Extra Help in
Chapter 2, Section 7.
What if you believe you have qualified for “Extra Help”
If you believe you have qualified for Extra Help and you believe that you are paying an incorrect
copayment amount when you get your prescription at a pharmacy, our plan has established a
process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us. [Note: Insert
plan’s process for allowing beneficiaries to request assistance with obtaining best available
evidence, and for providing this evidence.]
When we receive the evidence showing your copayment level, we will update our system so that
you can pay the correct copayment when you get your next prescription at the pharmacy. If you
overpay your copayment, we will reimburse you. Either we will forward a check to you in the
amount of your overpayment or we will offset future copayments. If the pharmacy hasn’t
collected a copayment from you and is carrying your copayment as a debt owed by you, we may
make the payment directly to the pharmacy. If a state paid on your behalf, we may make
payment directly to the state. Please contact Member Services if you have questions.

SECTION 5

Chapter 1
Section 5.1

Please keep your plan membership
record up to date

How to help make sure that we have
accurate information about you

[In the heading and this section, plans should substitute the name used for this file if different
from “membership record.”]
Your membership record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage.
The pharmacists in the plan’s network need to have correct information about you. These
network providers use your membership record to know what drugs are covered for you.
Because of this, it is very important that you help us keep your information up to date.
Call Member Services to let us know about these changes:
•

Changes to your name, your address, or your phone number

•

Changes in any other medical or drug insurance coverage you have (such as from your
employer, your spouse’s employer, workers’ compensation, or Medicaid)

2010 Evidence of Coverage for [insert plan name]
Chapter 1: Getting started as a member of [insert plan name]

•

If you have any liability claims, such as claims from an automobile accident

•

If you have been admitted to a nursing home

11

Read over the information we send you about any other insurance coverage you
have
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That’s because we must coordinate any other coverage you
have with your benefits under our plan.
Once each year, we will send you a letter that lists any other medical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don’t need to
do anything. If the information is incorrect, or if you have other coverage that is not listed, please
call Member Services (phone numbers are on the cover of this booklet).

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

11

CHAPTER 2: Important phone numbers and resources
SECTION 1. [Insert plan name] (how to contact us, including how
to reach Member Services at the plan) ................................................ [xx]
SECTION 2. Medicare (how to get help and information directly
from the Federal Medicare program) ................................................... [xx]
SECTION 3. State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare) .............. [xx]
SECTION 4. Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare) ........................ [xx]
SECTION 5. Social Security ................................................................................... [xx]
SECTION 6. Medicaid (a joint Federal and state program that helps with medical
costs for some people with limited income and resources) .................. [xx]
SECTION 7. Information about programs to help people pay for their
prescription drugs ............................................................................. [xx]
SECTION 8. How to contact the Railroad Retirement Board .............................. [xx]
SECTION 9. Do you have “group insurance” or other health insurance
coverage from an employer?............................................................ [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

SECTION 1

12

[Insert plan name]
(how to contact us, including how to reach
Member Services at the plan)

How to contact our plan’s Member Services
For assistance with enrollment, billing, or member card questions, please call or write to [insert
plan name] Member Services. We will be happy to help you.
[Insert plan name] Member Services
CALL

[Insert phone number(s)]

TTY/TDD

Calls to this number are [insert if applicable: not] free. [Insert hours
of operation, including information on the use of alternative
technologies.]
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

Calls to this number are [insert if applicable: not] free. [Insert hours
of operation.]
[Insert fax number]

WRITE

[Insert address]

WEBSITE

[Note: plans may add email addresses here.]
[Insert URL]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

13

[Note: If your plan uses the same contact information for the Part D coverage determinations,
appeals, and/or complaints, you may combine the appropriate sections below.]
How to contact us when you are asking for a coverage
decision about your Part D prescription drugs
[Insert plan name] Coverage Decisions for Part D Prescription Drugs
CALL

[Insert phone number]

TTY/TDD

Calls to this number are [insert if applicable: not] free. [Note: You
may also include reference to 24-hour lines here.] [Note: If you have
a different number for accepting expedited coverage determinations,
also include that number here.]
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

WRITE

Calls to this number are [insert if applicable: not] free. [Note: If you
have a different TTY/TDD number for accepting expedited coverage
determinations, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited coverage determinations, also
include that number here.]
[Insert address] [Note: If you have a different address for accepting
expedited coverage determinations, also include that address here.]

For more information on asking for coverage decisions about your Part D prescription drugs,
see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints).
How to contact us when you are making an appeal about your
Part D prescription drugs
[Insert plan name] Appeals for Part D Prescription Drugs
CALL

[Insert phone number]
Calls to this number are [insert if applicable: not] free. [Note: You
may also include reference to 24-hour lines here.] [Note: If you have
a different number for accepting expedited appeals, also include that
number here.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

TTY/TDD

14

[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

WRITE

Calls to this number are [insert if applicable: not] free. [Note: If you
have a different TTY/TDD number for accepting expedited appeals,
also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited appeals, also include that number
here.]
[Insert address] [Note: If you have a different address for accepting
expedited appeals, also include that address here.]

For more information on making an appeal about your Part D prescription drugs, see Chapter
7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
How to contact us when you are making a complaint about
your Part D prescription drugs
[Insert plan name] Complaints about Part D prescription drugs
CALL

[Insert phone number]

TTY/TDD

Calls to this number are [insert if applicable: not] free. [Note: You
may also include reference to 24-hour lines here.] [Note: If you have
a different number for accepting expedited grievances, also include
that number here.]
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX

WRITE

Calls to this number are [insert if applicable: not] free. [Note: If you
have a different TTY/TDD number for accepting expedited
grievances, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited grievances, also include that number
here.]
[Insert address] [Note: If you have a different address for accepting
expedited grievances, also include that address here.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

For more information on making a complaint about your Part D prescription drugs, see
Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints).
Where to send a request that asks us to pay for our share of
the cost of a drug you have received
The coverage determination process includes determining requests that asks us to
pay for our share of the costs of a drug that you have received. For more information
on situations in which you may need to ask the plan for reimbursement or to pay a
bill you have received from a provider, see Chapter 5 (Asking the plan to pay its
share of the cost of a drug).
[Insert plan name] Payment Requests
CALL

[Insert phone number]

TTY/TDD

Calls to this number are [insert if applicable: not] free.
[Insert number]
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

FAX
WRITE

SECTION 2

Calls to this number are [insert if applicable: not] free.
[Optional: Insert fax number]
[Insert address]

Medicare
(how to get help and information directly from
the Federal Medicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services
(sometimes called “CMS”). This agency contracts with and regulates Medicare prescription
drug plans including [insert plan name].

15

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

16

Medicare
CALL

1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.

TTY

1-877-486-2048
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.

WEBSITE

Calls to this number are free.
http://www.medicare.gov
This is the official government website for Medicare. It gives you upto-date information about Medicare and current Medicare issues. It
also has information about hospitals, nursing homes, physicians,
home health agencies, and dialysis facilities. It includes booklets you
can print directly from your computer. It has tools to help you
compare Medicare Advantage Plans and Medicare drug plans in your
area. You can also find Medicare contacts in your state by selecting
“Helpful Phone Numbers and Websites.”
If you don’t have a computer, your local library or senior center may
be able to help you visit this website using its computer. Or, you can
call Medicare at the number above and tell them what information
you are looking for. They will find the information on the website,
print it out, and send it to you.

SECTION 3

State Health Insurance Assistance
Program
(free help, information, and answers to your
questions about Medicare)

[Organizations offering plans in multiple states: Revise this section to use the generic name
(“State Health Insurance Assistance Program”) when necessary, and include a list of names,
phone numbers, and addresses for all SHIPs in your service area. Plans have the option of

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

17

including a separate exhibit to list the SHIPs in all states, or in all states in which the plan is
filed, and should make reference to that exhibit below.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. In [insert state], the State Health Insurance Assistance Program is
called [insert state-specific SHIP name].
[Insert state-specific SHIP name] is independent (not connected with any insurance company
or health plan). It is a state program that gets money from the Federal government to give free
local health insurance counseling to people with Medicare.
[Insert state-specific SHIP name] counselors can help you with your Medicare questions or
problems. They can help you understand your Medicare rights, help you make complaints
about your medical care or treatment, and help you straighten out problems with your
Medicare bills. [Insert state-specific SHIP name] counselors can also help you understand
your Medicare plan choices and answer questions about switching plans.
[Insert state-specific SHIP name]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 4

Quality Improvement Organization
(paid by Medicare to check on the quality of care
for people with Medicare)

[Organizations offering plans in multiple states: Revise this section to use the generic name
(“Quality Improvement Organization”) when necessary, and include a list of names, phone
numbers, and addresses for all QIOs in your service area. Plans have the option of including
a separate exhibit to list the QIOs in all states, or in all states in which the plan is filed, and
should make reference to that exhibit below.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

18

There is a Quality Improvement Organization in each state. In [insert state], the Quality
Improvement Organization is called [insert state-specific QIO name].
[Insert state-specific QIO name] has a group of doctors and other health care professionals
who are paid by the Federal government. This organization is paid by Medicare to check on
and help improve the quality of care for people with Medicare. [Insert state-specific QIO
name] is an independent organization. It is not connected with our plan.
You should contact [insert state-specific QIO name] in any of these situations:
•

You have a complaint about the quality of care you have received.

•

You think coverage for your hospital stay is ending too soon.

•

You think coverage for your home health care, skilled nursing facility care, or outpatient
rehabilitation care is ending too soon.

[Insert state-specific QIO name]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 5

Social Security

Social Security is responsible for determining eligibility and handling enrollment for
Medicare. U.S. citizens who are 65 or older, or who have a disability or end stage renal
disease and meets certain conditions, are eligible for Medicare. If you are already getting
Social Security checks, enrollment into Medicare is automatic. If you are not getting Social
Security checks, you have to enroll in Medicare and pay the Part A premium. Social Security
handles the enrollment process for Medicare. To apply for Medicare, you can call the Social
Security or visit your local Social Security office.

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

19

Social Security Administration
CALL

1-800-772-1213
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
You can use our automated telephone services to get recorded
information and conduct some business 24 hours a day.

TTY

1-800-325-0778
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.

WEBSITE

SECTION 6

http://www.ssa.gov

Medicaid
(a joint Federal and state program that helps
with medical costs for some people with
limited income and resources)

[Organizations offering plans in multiple states: Revise this section to include a list of agency
names, phone numbers, and addresses for all states in your service area. Plans have the
option of including a separate exhibit to list Medicaid information in all states or in all states
in which the plan is filed and should make reference to that exhibit below.]
[Plans may adapt this generic discussion of Medicaid to reflect the name or features of the
Medicaid program in the plan’s state or states.]
Medicaid is a joint Federal and state government program that helps with medical costs for
certain people with limited incomes and resources. Some people with Medicare are also
eligible for Medicaid. Medicaid has programs that can help pay for your Medicare premiums

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

20

and other costs, if you qualify. To find out more about Medicaid and its programs, contact
[insert state-specific Medicaid agency].
[Insert state-specific Medicaid agency]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only
for people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 7

Information about programs to help
people pay for their prescription drugs

Medicare’s “Extra Help” Program
Medicare provides “Extra Help” to pay prescription drug costs for people who have limited
income and resources. Resources include your savings and stocks, but not your home or car. If
you qualify, you get help paying for any Medicare drug plan’s monthly premium, [insert if
applicable: yearly deductible,] and prescription [insert as applicable: copayments OR
coinsurance]. This Extra Help also counts toward your out-of-pocket costs.
People with limited income and resources may qualify for Extra Help. Some people
automatically qualify for Extra Help and don’t need to apply. Medicare mails a letter to people
who automatically qualify for Extra Help.
If you think you may qualify for Extra Help, call Social Security (see Section 5 of this chapter
for contact information) to apply for the program. You may also be able to apply at your State
Medical Assistance or Medicaid Office (see Section 6 of this chapter for contact information).
After you apply, you will get a letter letting you know if you qualify for Extra Help and what you
need to do next.
State Pharmaceutical Assistance Programs
[Plans without an SPAP in their state(s), should delete this section.]

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

21

[Organizations offering plans in multiple states: Revise this section to include a list of SPAP
names, phone numbers, and addresses for all states in your service area. Plans have the
option of including a separate exhibit to list the SPAPs in all states or in all states in which
the plan is filed and should make reference to that exhibit below.]
Many states have State Pharmaceutical Assistance Programs that help some people pay for
prescription drugs based on financial need, age, or medical condition. Each state has different
rules to provide drug coverage to its members.
In [insert state name], the [insert state-specific SPAP name] is a state organization that provides
limited income and medically needy seniors and individuals with disabilities financial help for
prescription drugs.
[Insert state-specific SPAP name]
CALL

[Insert phone number(s)]

TTY/TDD

[Insert number, if available. Or delete this row.]

WRITE

This number requires special telephone equipment and is only
for people who have difficulties with hearing or speaking.
[Insert address]

WEBSITE

[Optional: Insert URL]

SECTION 8

How to contact the Railroad Retirement
Board

The Railroad Retirement Board is an independent Federal agency that administers
comprehensive benefit programs for the nation’s railroad workers and their families. If you have
questions regarding your benefits from the Railroad Retirement Board, contact the agency.
Railroad Retirement Board

2010 Evidence of Coverage for [insert plan name]
Chapter 2: Important phone numbers and resources

CALL

22

1-877-772-5772
Calls to this number are free.
Available 9:00 am to 3:30 pm, Monday through Friday

TTY

If you have a touch-tone telephone, recorded information and
automated services are available 24 hours a day, including
weekends and holidays.
1-312-751-4701
This number requires special telephone equipment and is only
for people who have difficulties with hearing or speaking.
Calls to this number are not free.

WEBSITE

SECTION 9

http://www.rrb.gov

Do you have “group insurance” or other
health insurance from an employer?

If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group, call
the employer/union benefits administrator or Member Services if you have any questions. You
can ask about your (or your spouse’s) employer or retiree health or drug benefits, premiums, or
enrollment period.
If you have other prescription drug coverage through your (or your spouse’s) employer or
retiree group, please contact that group’s benefits administrator. The benefits administrator
can help you determine how your current prescription drug coverage will work with our plan.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

23

CHAPTER 3: Using the plan’s coverage for your Part D prescription drugs

SECTION 1. Introduction
1.1

This chapter describes your coverage for Part D drugs ............................................ [xx]

1.2

Basic rules for the plan’s Part D drug coverage ....................................................... [xx]

SECTION 2. Fill your prescription at a network pharmacy or through
the plan’s mail order service
2.1

To have your prescription covered, use a network pharmacy .................................[xx]

2.2

Finding network pharmacies ..................................................................................... [xx]

2.3

Using the plan’s mail order services ......................................................................... [xx]

2.4 How can you get a longer-term supply of drugs? .................................................... [xx]
2.5

When can you use a pharmacy that is not in the plan’s network? ........................... [xx]

SECTION 3. Your drugs need to be on the Plan’s “Drug List”
3.1

The Drug List tells which Part D drugs are covered.................................................[xx]

3.2

There are [insert number of cost groups] “Cost Groups” for drugs on the Drug
List ............................................................................................................................ [xx]

3.3 How can you find out if a specific drug is on the Drug List?...................................[xx]
SECTION 4. There are restrictions on coverage for some drugs
4.1

What kinds of restrictions? ....................................................................................... [xx]

4.2

Why do some drugs have restrictions? ..................................................................... [xx]

4.3

Do any of these restrictions apply to your drugs?..................................................... [xx]

SECTION 5. What if one of your drugs is not covered in the way
you’d like it to be covered?
5.1 There are things you can do if your drug is not covered in the way you’d like it
to be covered .............................................................................................................. [xx]
5.2 What can you do if a drug is not on the Drug List or if it is restricted in some
way? ........................................................................................................................... [xx]
5.3 What can you do if your drug is in a Cost Group you think is too high? .................. [xx]
SECTION 6. What if your coverage changes for one of your drugs?
6.1

The Drug List can change during the year ...............................................................[xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

6.2

24

What happens if coverage changes for a drug you are taking?................................. [xx]

SECTION 7. What types of drugs are not covered by the plan?
7.1

Types of drugs we do not cover ...............................................................................[xx]

SECTION 8. Show your plan membership card when you fill a prescription
8.1 Show your membership card ...................................................................................[xx]
8.2

What if you don’t have your membership card with you? ....................................... [xx]

SECTION 9. Part D drug coverage in special situations
9.1

What if you’re in a hospital or a skilled nursing facility for a stay
that is covered by Original Medicare? ...................................................................... [xx]

9.2

What if you’re a resident in a long-term care facility? ............................................. [xx]

9.3

What if you are taking drugs covered by Original Medicare? .................................. [xx]

9.4

What if you have a Medigap (Medicare Supplement Insurance)
policy with prescription drug coverage? ................................................................... [xx]

9.5

What if you’re also getting drug coverage from an employer or
retiree group plan? .................................................................................................... [xx]

SECTION 10. Programs on drug safety and managing medications
10.1

Programs to help members use drugs safely ............................................................. [xx]

10.2

Programs to help members manage their medications ............................................. [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

25

[Delete this box if this is your LIS EOC.]
Did you know there are programs to help
people pay for their drugs?
[Insert as appropriate, depending on whether SPAPs are discussed in Chapter 2:
There are programs to help people with limited resources pay for their drugs.
These include “Extra Help” and State Pharmaceutical Assistance Programs. OR
The “Extra Help” program helps people with limited resources pay for their
drugs.] For more information, see Chapter 2, Section 7.
Are you currently getting help to pay for
your drugs?
If you are in a program that helps pay for your drugs, some information in this
Evidence of Coverage is not correct for you. Please call Member Services and
ask for the Evidence of Coverage for people who get extra help paying for drugs.
Phone numbers for Member Services are on the front cover.

SECTION 1

Chapter 3
Section 1.1

Introduction

This chapter describes your coverage for
Part D drugs

This chapter explains rules for using your coverage for Part D drugs. The next chapter tells what
you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs).
In addition to your coverage for Part D drugs through our plan, Original Medicare (Medicare
Part A and Part B) also covers some drugs:
•

Medicare Part A covers drugs you are given during Medicare-covered stays in the
hospital or in a skilled nursing facility.

•

Medicare Part B also provides benefits for some drugs. Part B drugs include certain
chemotherapy drugs, drug injections you are given during an office visit, and drugs
you are given at a dialysis facility.

The two types of drugs described above are covered by Original Medicare. To find out more
about this coverage, see your Medicare & You handbook.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

26

This chapter explains rules for using your coverage for Part D drugs under our plan. The
next chapter tells what you pay for Part D drugs (Chapter 4, What you pay for your Part D
prescription drugs).

Chapter 3
Section 1.2

Basic rules for the plan’s Part D drug
coverage

The plan will generally cover your drugs as long as you follow these basic rules:
•

You must use a network pharmacy to fill your prescription. (See Section 2, Fill your
prescriptions at a network pharmacy.)

•

Your drug must be on the plan’s List of Covered Drugs (Formulary) (we call it the “Drug
List” for short). (See Section 3, Your drugs need to be on the plan’s drug list.)

•

Your drug must be considered medically necessary, meaning reasonable and
necessary for treatment of your illness or injury. It also needs to be prescribed for
an accepted treatment for your medical condition.

SECTION 2

Chapter 3
Section 2.1

Fill your prescription at a network
pharmacy or through the plan’s mail
order service

To have your prescription covered, use a
network pharmacy

In most cases, your prescriptions are covered only if they are filled at the plan’s network
pharmacies.
A network pharmacy is a pharmacy that has a contract with the plan to provide your covered
prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are
covered by the plan.
[Include if plan has both preferred and non-preferred pharmacies in their networks: Preferred
pharmacies are pharmacies in our network where the plan has negotiated lower cost-sharing for
members for covered drugs than at [insert either: non-preferred pharmacies OR other network
pharmacies]. However, you will still have access to lower drug prices at [insert either: nonpreferred pharmacies OR these other network pharmacies] than at out-of-network pharmacies.
You may go to either of these types of network pharmacies to receive your covered prescription

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

27

drugs. [Describe restrictions imposed on members that use non-preferred pharmacies.]]

Chapter 3
Section 2.2

Finding network pharmacies

How do you find a network pharmacy in your area?
You can look in your Pharmacy Directory, visit our website ([insert URL]), or call Member
Services (phone numbers are on the cover). Choose whatever is easiest for you.
You may go to any of our network pharmacies. If you switch from one network pharmacy to
another, and you need a refill of a drug you have been taking, you can ask to [insert if
applicable: either have a new prescription written by a doctor or] to have your prescription
transferred to your new network pharmacy.
What if the pharmacy you have been using leaves the network?
If the pharmacy you have been using leaves the plan’s network, you will have to find a new
pharmacy that is in the network. To find another network pharmacy in your area, you can get
help from Member Services (phone numbers are on the cover) or use the Pharmacy Directory.
What if you need a non-retail, network pharmacy?
Sometimes prescriptions must be filled at a non-retail, network pharmacy. Non-retail,
network pharmacies include:
•

Pharmacies that supply drugs for home infusion therapy. [Plans may insert additional
information about home infusion pharmacy services in the plan’s network.]

•

Pharmacies that supply drugs for residents of a long-term-care facility. Usually, a
long-term care facility (such as a nursing home) has its own pharmacy. Residents may
get prescription drugs through the facility’s pharmacy as long as it is part of our
network. If your long-term care pharmacy is not in our network, please contact
Member Services. [Plans may insert additional information about LTC pharmacy
services in the plan’s network.]

•

Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health
Program. Except in emergencies, only Native Americans or Alaska Natives have
access to these pharmacies in our network. [Plans may insert additional information
about I/T/U pharmacy services in the plan’s network.]

To locate a non-retail, network pharmacy, look in your Pharmacy Directory or call Member
Services.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

Chapter 3
Section 2.3

28

Using the plan’s mail-order services

[Omit section if the plan does not offer mail-order services.]
[Include the following information only if your mail-order service is limited to a subset of all
formulary drugs, adapting terminology as needed: For certain kinds of drugs, you can use the
plan’s network mail-order services. These drugs are marked as [insert either: “maintenance”
OR “mail order”] drugs on our plan’s Drug List. ([Insert either: Maintenance OR Mail order]
drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)]
Our plan’s mail-order service requires you to order [insert either: at least a [XX]-day supply of
the drug and no more than a [XX]-day supply OR up to a [XX] day supply].
To get [insert if applicable: order forms and] information about filling your prescriptions by mail
[insert instructions]. If you use a mail order pharmacy not in the plan’s network, your prescription
will not be covered.
Usually a mail-order pharmacy order will get to you in no more than [XX] days. [Insert plan’s
process for members to get a prescription if the mail-order is delayed.]

Chapter 3
Section 2.4

How can you get a longer-term supply of
drugs?

When you get a longer-term supply of drugs, your cost sharing may be lower. The plan offers
[insert as appropriate: a way OR two ways] to get a longer-term supply of [insert either:
“maintenance” OR “mail order”] drugs on our plan’s Drug List. ([Insert either: Maintenance OR
Mail order] drugs are drugs that you take on a regular basis, for a chronic or long-term medical
condition.)
1. Some retail pharmacies in our network allow you to get a longer-term supply of [insert
either: maintenance OR mail order] drugs. Some of these retail pharmacies [insert if
applicable: may] agree to accept [insert as appropriate: a lower OR the mail-order] costsharing amount for a longer-term supply of [insert either: maintenance OR mail order]
drugs. [Insert if applicable: Other retail pharmacies may not agree to accept the [insert as
appropriate: lower OR mail-order] cost-sharing amounts for an extended supply of
[insert either: maintenance OR mail order] drugs. In this case you will be responsible for
the difference in price.] Your Pharmacy Directory tells you which pharmacies in our
network can give you a longer-term supply of [insert either: maintenance OR mail order]
drugs. You can also call Member Services for more information.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

29

2. [Delete if plan does not offer mail order service.] For certain kinds of drugs, you can use
the plan’s network mail-order services. These drugs are marked as [insert either:
maintenance OR mail order] drugs on our plan’s Drug List. Our plan’s mail-order service
requires you to order [insert either: at least a [XX]-day supply of the drug and no more
than a [XX]-day supply OR up to a [XX] day supply]. See Section 3.3 for more
information about using our mail-order services.

Chapter 3
Section 2.5

When can you use a pharmacy that is not
in the plan’s network?

Your prescription might be covered in certain situations
[Insert if applicable: We have network pharmacies outside of our service area where you can get
your prescriptions filled as a member of our plan.] Generally, we cover drugs filled at an out-ofnetwork pharmacy only when you are not able to use a network pharmacy. Here are the
circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
•

[Plans should insert a list of situations when they will cover prescriptions out of the
network and any limits on their out-of-network policies (e.g., day supply limits, use of
mail-order during extended out of area travel, authorization or plan notification).]

In these situations, please check first with Member Services to see if there is a network
pharmacy nearby.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather
than paying your normal share of the cost) when you fill your prescription. You can ask us to
reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to
pay you back.)

SECTION 3

Chapter 3
Section 3.1

Your drugs need to be on the plan’s
“Drug List”

The “Drug List” tells which Part D drugs
are covered

The plan has a “List of Covered Drugs (Formulary).” In this Evidence of Coverage, we call it
the “Drug List” for short.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

30

The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.
The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List.
The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter,
Section 1.1 explains about Part D drugs).
We will generally cover a drug on the plan’s Drug List as long as you follow the other
coverage rules explained in this chapter and the drug is medically necessary, meaning
reasonable and necessary for treatment of your illness or injury. It also needs to be
prescribed for an accepted treatment for your medical condition.
The Drug List includes both brand-name and generic drugs
A generic drug is a prescription drug that has the same active ingredients as the brand-name
drug. It works just as well as the brand-name drug, but it costs less. There are generic drug
substitutes available for many brand-name drugs.
What is not on the Drug list?
The plan does not cover all prescription drugs.
•

In some cases, the law does not allow any Medicare plan to cover certain types of
drugs (for more about this, see Section 8.1 in this chapter).

•

In other cases, we have decided not to include a particular drug on our Drug List.

Chapter 3
Section 3.2

There are [insert number of cost groups]
“Costs Groups” for drugs on the Drug
List

[Plans that do not use drug cost groups should omit this section.]
Every drug on the plan’s Drug List is in one of [insert number of cost groups] Cost Groups. In
general, the higher the Cost Group number, the higher your cost for the drug:
•

[Plans should briefly describe each cost group (e.g., Cost Group 1 includes generic
drugs). Indicate which is the lowest cost group and which is the highest cost group.]

To find out which Cost Group your drug is in, look it up in the plan’s Drug List.
The amount you pay for drugs in each Cost Group is shown in Chapter 4 (What you pay for your
Part D prescription drugs).

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

Chapter 3
Section 3.3

31

How can you find out if a specific drug is
on the Drug List?

You have three ways to find out:
1. Check the most recent Drug List we sent you in the mail.
2. Visit the plan’s website ([insert URL]). The Drug List on the website is always
the most current.
3. Call Member Services to find out if a particular drug is on the plan’s Drug List or
to ask for a copy of the list. Phone numbers for Member Services are on the front
cover.

SECTION 4

Chapter 3
Section 4.1

There are restrictions on coverage for
some drugs

What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effective
ways. The sections below tell you more about the types of restrictions we use for certain drugs.
[Plans should include only the forms of utilization management used by the plan:]
Using generic drugs whenever you can
A “generic” drug works the same as a brand-name drug, but usually costs less. When a generic
version of a brand-name drug is available, our network pharmacies must provide you the
generic version. However, if your doctor has told us the medical reason that the generic drug
will not work for you, then we will cover the brand-name drug. (Your share of the cost may be
greater for the brand-name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your doctor need to get approval from the plan before we will agree to
cover the drug for you. This is called “prior authorization.” Sometimes plan approval is required
so we can be sure that your drug is covered by Medicare rules. Sometimes the requirement for
getting approval in advance helps guide appropriate use of certain drugs. If you do not get this
approval, your drug might not be covered by the plan.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

32

Trying a different drug first
This requirement encourages you to try safer or more effective drugs before the plan covers
another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may
require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug
B. This requirement to try a different drug first is called “Step Therapy.”
Quantity limits
For certain drugs, we limit the amount of the drug that you can have. For example, the plan
might limit how many refills you can get, or how much of a drug you can get each time you fill
your prescription. For example, if it is normally considered safe to take only one pill per day for
a certain drug, we may limit coverage for your prescription to no more than one pill per day.

Chapter 3
Section 4.2

Why do some drugs have restrictions?

For certain prescription drugs, special rules restrict how and when the plan covers them. A team
of doctors and pharmacists developed these rules to help our members use drugs in the most
effective ways. These special rules also help control overall drug costs, which keeps your drug
coverage more affordable.
In general, our rules encourage you get a drug that works for your medical condition and is safe.
Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the
plan’s rules are designed to encourage you and your doctor or other prescriber to use that lowercost option. We also need to comply with Medicare’s rules and regulations for drug coverage and
cost sharing.
Chapter 3
Section 4.3

Do any of these restrictions apply to your
drugs?

The plan’s Drug List includes information about the restrictions described above. To find out if
any of these restrictions apply to a drug you take or want to take, check the Drug List. For the
most up-to-date information, call Member Services (phone numbers are on the front cover) or
check our website ([insert URL]).

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

SECTION 5

Chapter 3
Section 5.1

33

What if one of your drugs is not
covered in the way you’d like it to be
covered?

There are things you can do if your drug
is not covered in the way you’d like it to
be covered

Suppose there is a prescription drug you are currently taking, or one that you and your doctor
think you should be taking. We hope that your drug coverage will work well for you, but it’s
possible that you might have a problem. For example:
•

What if the drug you want to take is not covered by the plan? For example, the drug
might not be covered at all. Or maybe a generic version of the drug is covered but the
brand-name version you want to take is not covered.

•

What if the drug is covered, but there are extra rules or restrictions on coverage for
that drug? As explained in Section 4, some of the drugs covered by the plan have extra
rules to restrict their use. For example, [Delete if plan does not have step therapy: you
might be required to try a different drug first, to see if it will work, before the drug you
want to take will be covered for you.] [Delete if plan does not have quantity limits: Or
there might be limits on what amount of the drug (number of pills, etc.) is covered during
a particular time period.]

•

[Omit if plan does not use drug cost groups: What if the drug is covered, but it is in a
Cost Group that makes your cost sharing more expensive than you think it should
be? The plan puts each covered drug into one of [insert number of cost groups] different
Cost Groups. How much you pay for your prescription depends in part on which Cost
Group your drug is in.]

There are things you can do if your drug is not covered in the way that you’d like it to be
covered. [Delete if plan does not use drug cost groups: Your options depend on what type of
problem you have:]
•

If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn
what you can do.

•

[Omit if plan does not use drug cost groups] If your drug is in a Cost Group that makes
your cost more expensive than you think it should be, go to Section 5.3 to learn what you
can do.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

Chapter 3
Section 5.2

34

What can you do if your drug is not on
the Drug List or if the drug is restricted in
some way?

If your drug is not on the Drug List or is restricted, here are things you can do:
•

You can change to another drug, or

•

You can file an exception and ask the plan to cover the drug in the way you would like it
to be covered.

You may be able to get a temporary supply of their drug (only members in certain situations can
get a temporary supply) until you and your doctor decide it is okay to change to another drug, or
while you file an exception.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your
drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to
talk with your doctor about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
•

The drug you have been taking is not on the plan’s Drug List.

•

-- or -- the drug you have been taking is now restricted in some way (Section 4 in this
chapter tells about restrictions).

2. You must be in one of the situations described below:
•

[Plans may omit this scenario if they allow current members to request formulary
exceptions in advance for the following year:] For those members who were in the
plan last year:
We will cover a temporary supply of your drug one time only during the first [insert
time period (must be at least 90 days)] of the calendar year. This temporary supply will
be for a maximum of [insert supply limit (must be at least a 30-day supply)], or less if
your prescription is written for fewer days.

•

For those members who are new to the plan and aren’t in a long-term care facility:
We will cover a temporary supply of your drug one time only during the first [insert
time period (must be at least 90 days)] of your membership in the plan. This temporary
supply will be for a maximum of [insert supply limit (must be at least a 30-day supply)],

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

35

or less if your prescription is written for fewer days. The prescription must be filled at a
network pharmacy.
•

For those who are new members, and are residents in a long-term-care
facility:
We will cover a temporary supply of your drug during the first [insert time period
(must be at least 90 days)] of your membership in the plan. The first supply will be for
a maximum of [insert supply limit (must be at least a 31-day supply)], or less if your
prescription is written for fewer days. If needed, we will cover additional refills during
your first [insert time period (must be at least 90 days)] in the plan.

•

If you have been a member of the plan for more than [insert time period (must be at
least 90 days)] and you are a resident of a long-term care facility, we will cover one
[insert supply limit (must be at least a 31-day supply)] supply, or less if your prescription
is written for fewer days. This is in addition to the above LTC transition supply.

•

[If applicable: Plans must insert their transition policy for current members with level of
care changes.]

To ask for a temporary supply, call Member Services (phone numbers are on the front cover.)
During the time when you are getting a temporary supply of a drug, you should talk with your
doctor or other prescriber to decide what to do when your temporary supply runs out. Perhaps
there is a different drug covered by the plan that might work just as well for you. Or you and
your doctor can ask the plan to make an exception for you and cover the drug in the way you
would like it to be covered. The sections below tell you more about these options.
You can change to another drug
Start by talking with your doctor or other prescriber. Perhaps there is a different drug covered by
the plan that might work just as well for you. You can call Member Services to ask for a list of
covered drugs that treat the same medical condition. This list can help your doctor to find a
covered drug that might work for you.
You can file an exception
You and your doctor or other prescriber can ask the plan to make an exception for you and cover
the drug in the way you would like it to be covered. If your doctor or other prescriber says that
you have medical reasons that justify asking us for an exception, your doctor or other prescriber
can help you request an exception to the rule.
For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List.
Or you can ask the plan to make an exception and cover the drug without restrictions.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

36

[Plans that allow current members to receive a temporary supply instead, may omit the
following paragraph:] If you are a current member and a drug you are taking will be removed
from the formulary or restricted in some way for next year, we will allow you to request a
formulary exception in advance for next year. We will tell you about any change in the coverage
for your drug for the following year. You can then ask us to make an exception and cover the
drug in the way you would like it to be covered for the following year. We will give you an
answer to your request for an exception before the change takes effect.
If you and your doctor or other prescriber want to ask for an exception, Chapter 7 tells what to
do. It explains the procedures and deadlines that have been set by Medicare to make sure your
request is handled promptly and fairly.

Chapter 3
Section 5.3

What can you do if your drug is in a Cost
Group you think is too high?

[Plans that do not use drug cost groups: omit this section.]
If your drug is a Cost Group you think is too high, here are things you can do:
You can change to another drug
Start by talking with your doctor or other prescriber. Perhaps there is a different drug in a lower
Cost Group that might work just as well for you. You can call Member Services to ask for a list
of covered drugs that treat the same medical condition. This list can help your doctor or other
prescriber to find a covered drug that might work for you.
You can file an exception
You and your doctor or other prescriber can ask the plan to make an exception in the Cost Group
for the drug so that you pay less for the drug. If your doctor or other prescriber says that you
have medical reasons that justify asking us for an exception, your doctor or other prescriber can
help you request an exception to the rule.
If you and your doctor or other prescriber want to ask for an exception, Chapter 7 tells what to
do. It explains the procedures and deadlines that have been set by Medicare to make sure your
request is handled promptly and fairly.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

SECTION 6

Chapter 3
Section 6.1

37

What if your coverage changes for one of
your drugs?

The Drug List can change during the year

Most of the changes in drug coverage happen at the beginning of each year (January 1).
However, during the year, the plan might make many kinds of changes to the Drug List. For
example, the plan might:
•

Add or remove drugs from the Drug List. New drugs become available,
including new generic drugs. Perhaps the government has given approval to a new
use for an existing drug. Sometimes, a drug gets recalled and we need to stop
using it right away. Or we might remove a drug from the list because it has been
found to be ineffective.

•

[Delete this bullet if plan does not use drug cost groups:] Move a drug to a
higher or lower Cost Group.

•

Add or remove a restriction on coverage for a drug (for more about
restrictions to coverage, see Section 4 in this chapter).

•

Replace a brand-name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug
List.

Chapter 3
Section 6.2

What happens if coverage changes for a
drug you are taking?

How will you find out if your drug’s coverage has been changed?
If there is a change to coverage for a drug you are taking, the plan will send you a notice
to tell you. Normally, we will let you know at least 60 days ahead of time.
Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for
other reasons. If this happens, the plan will immediately remove the drug from the Drug
List. We will let you know of this change right away. Your doctor will also know about
this change, and can work with you to find another drug for your condition.
Do changes to your drug coverage affect you right away?

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

If any of the following types of changes affect a drug you are taking, the change will not
affect you until January 1 of the next year if you stay in the plan:
•

[Plans that do not use cost groups, omit this bullet] If we move your drug into a
higher Cost Group.

•

If we put a new restriction on your use of the drug.

•

If we remove your drug from the Drug List, but not because of a sudden recall or
because a new generic drug has replaced it.

If any of these changes happens for a drug you are taking, then the change won’t affect
your use or what you pay as your share of the cost until January 1 of the next year. Until
that date, you probably won’t see any increase in your payments or any added restriction
to your use of the drug. However, on January 1 of the next year, the changes will affect
you.
In some cases, you will be affected by the coverage change before January 1:
•

If a brand-name drug you are taking is replaced by a new generic drug, the
plan must give you at least 60 days’ notice or give you a 60-day refill of your
brand-name drug at a network pharmacy.
o During this 60-day period, you should be working with your doctor to
switch to the generic or to a different drug that we cover.
o Or you and your doctor or other prescriber can ask the plan to make an
exception and continue to cover the brand-name drug for you. For
information on how to ask for an exception, see Chapter 7 (What to do if
you have a problem or complaint).

•

If a drug is suddenly recalled because it’s been found to be unsafe or for other
reasons, the plan will immediately remove the drug from the Drug List. We will
let you know of this change right away.
o Your doctor or other prescriber will also know about this change, and can
work with you to find another drug for your condition.

38

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

SECTION 7

Chapter 3
Section 7.1

39

What types of drugs are not covered by
the plan?

Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” Excluded means that the
plan doesn’t cover these types of drugs because the law doesn’t allow any Medicare drug plan to
cover them.
If you get drugs that are excluded, you must pay for them yourself. We won’t pay for the drugs
that are listed in this section (unless our plan covers certain excluded drugs under supplemental
prescription drug coverage). The only exception: If the requested drug is found upon appeal to be
a drug that is not excluded under Part D and we should have paid for or covered because of your
specific situation. (For information about appealing a decision we have made to not cover a drug,
go to Chapter 9 in this booklet.)
Here are general rules about drugs that Medicare drug plans will not cover under Part D:
•

Our plan’s Part D drug coverage cannot cover a drug that would be covered under
Medicare Part A or Part B.

•

Our plan’s Part D drug coverage cannot cover a drug purchased outside the United States
and its territories.

•

In most situations, our plan’s Part D drug coverage cannot cover what are called “offlabel uses” of a prescription drug. “Off-label use” is any use of the drug other than those
indicated on a drug’s label as approved by the Food and Drug Administration.
o Sometimes off-label use is allowed. Medicare sometimes allows us to cover “offlabel uses” of a prescription drug. Coverage is allowed only when the use is
supported by certain reference books. These reference books are the American
Hospital Formulary Service Drug Information, the DRUGDEX Information
System, and the USPDI or its successor. If the use is not supported by any of
these reference books, then our plan cannot cover its “off-label use.”

Also, by law, these categories of drugs are not covered by Medicare drug plans unless an extra
premium is charged above the basic Part D plan premium:
•

Non-prescription drugs (also called over-the-counter drugs)

•

Drugs when used to promote fertility

•

Drugs when used for the relief of cough or cold symptoms

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

40

•

Drugs when used for cosmetic purposes or to promote hair growth

•

Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations

•

Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra,
Cialis, Levitra, and Caverject

•

Drugs when used for treatment of anorexia, weight loss, or weight gain

•

Outpatient drugs for which the manufacturer seeks to require that associated tests or
monitoring services be purchased exclusively from the manufacturer as a condition of
sale

•

Barbiturates and Benzodiazepines

[Insert if applicable: We offer additional coverage of some prescription drugs not normally
covered in a Medicare Prescription Drug Plan. [Insert details about the excluded drugs your plan
does cover, including whether you place any limits on that coverage.] The amount you pay when
you fill a prescription for these drugs does not count towards qualifying you for the Catastrophic
Coverage Stage. (The Catastrophic Coverage Stage is described in Chapter 4, Section 7 of this
booklet.)]
[Insert if plan offers coverage for any drugs excluded under Part D: In addition, if you are
receiving extra help from Medicare to pay for your prescriptions, the extra help will not pay
for the drugs not normally covered. (Please refer to your formulary or call Member Services for
more information.) However, your state Medicaid program may cover some prescription drugs
not normally covered in a Medicare drug plan. Please contact your state Medicaid program to
determine what drug coverage may be available to you.]
[Insert if plan does not offer coverage for any drugs excluded under Part D: If you receive
extra help paying for your drugs, your state Medicaid program may cover some prescription
drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program
to determine what drug coverage may be available to you.]

SECTION 8

Chapter 3
Section 8.1

Show your plan membership card when
you fill a prescription

Show your membership card

To fill your prescription, show your plan membership card at the network pharmacy you
choose. When you show your plan membership card, the network pharmacy will

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

41

automatically bill the plan for our share of your covered prescription drug cost. You will need
to pay the pharmacy your share of the cost when you pick up your prescription.

Chapter 3
Section 8.2

What if you don’t have your membership
card with you?

If you don’t have your plan membership card with you when you fill your prescription, ask the
pharmacy to call the plan to get the necessary information.
If the pharmacy is not able to get the necessary information, you may have to pay the full cost
of the prescription when you pick it up. (You can then ask us to reimburse you for our share.
See Chapter 5, Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 9

Chapter 3
Section 9.1

Part D drug coverage in special
situations

What if you’re in a hospital or a skilled
nursing facility for a stay that is covered
by Original Medicare?

If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will
generally cover the cost of your prescription drugs during your stay. Once you leave the hospital,
our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the
previous parts of this chapter that tell about the rules for getting drug coverage.
If you are admitted to a skilled nursing facility for a stay covered by Original Medicare,
Medicare Part A will generally cover your prescription drugs during all or part of your stay. If
you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan
will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous
parts of this chapter that tell about the rules for getting drug coverage.
Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a
special enrollment period. During this time period, you can leave this plan and join a new
Medicare Advantage plan or Original Medicare. (Chapter 8, Ending your membership in the
plan, tells you can leave our plan and join a different Medicare plan.)

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

Chapter 3
Section 9.2

42

What if you’re a resident in a long-term
care facility?

Usually, a long-term care facility (such as a nursing home) has its own pharmacy, or a pharmacy
that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you
may get your prescription drugs through the facility’s pharmacy as long as it is part of our
network.
Check your Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of
our network. If it isn’t, or if you need more information, please contact Member Services.
What if you’re a resident in a long-term care
facility and become a new member of the plan?
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a
temporary supply of your drug during the first [insert time period (must be at least 90 days)] of
your membership. The first supply will be for a maximum of [insert supply limit (must be at least
a 31-day supply)], or less if your prescription is written for fewer days. If needed, we will cover
additional refills during your first [insert time period (must be at least 90 days)] in the plan.
If you have been a member of the plan for more than [insert time period (must be at least 90
days)] and need a drug that is not on our Drug List or if the plan has any restriction on the drug’s
coverage, we will cover one [insert supply limit (must be at least a 31-day supply)] supply, or
less if your prescription is written for fewer days.
During the time when you are getting a temporary supply of a drug, you should talk with your
doctor or other prescriber to decide what to do when your temporary supply runs out. Perhaps
there is a different drug covered by the plan that might work just as well for you. Or you and
your doctor can ask the plan to make an exception for you and cover the drug in the way you
would like it to be covered. If you and your doctor want to ask for an exception, Chapter 7 tells
what to do.

Chapter 3
Section 9.3

What if you are taking drugs covered by
Original Medicare?

Your enrollment in [insert plan name] doesn’t affect your coverage for drugs covered under
Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will still
be covered under Medicare Part A or Part B, even though you are enrolled this plan. In
addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it,
even if you choose not to enroll in Part A or Part B.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

43

Some drugs may be covered under Medicare Part B in some situations and through [insert plan
name] in other situations. But drugs are never covered by both Part B and our plan at the same
time. In general, your pharmacist or provider will determine whether to bill Medicare Part B or
[insert plan name] for the drug.

Chapter 3
Section 9.4

What if you have a Medigap (Medicare
Supplement Insurance) policy with
prescription drug coverage?

If you currently have a Medigap policy that includes coverage for prescription drugs, you must
contact your Medigap issuer and tell them you have enrolled in our plan. If you decide to keep
your current Medigap policy, your Medigap issuer will remove the prescription drug coverage
portion of your Medigap policy and lower your premium.
Each year your Medigap insurance company should send you a notice by November 15 that tells
if your prescription drug coverage is “creditable,” and the choices you have for drug coverage.
(If the coverage from the Medigap policy is “creditable,” it means that it has drug coverage that
pays, on average, at least as much as Medicare’s standard drug coverage.) The notice will also
explain how much your premium would be lowered if you remove the prescription drug
coverage portion of your Medigap policy. If you didn’t get this notice, of if you can’t find it,
contact your Medicare insurance company and ask for another copy.

Chapter 3
Section 9.5

What if you’re also getting drug coverage
from an employer or retiree group plan?

Do you currently have other prescription drug coverage through your (or your spouse’s)
employer or retiree group? If so, please contact that group’s benefits administrator. He or
she can help you determine how your current prescription drug coverage will work with our
plan.
In general, if you are currently employed, the prescription drug coverage you get from us will be
secondary to your employer or retiree group coverage. That means your group coverage would
pay first.
Special note about ‘creditable coverage’:
Our plan will notify you each year to tell you whether the drug coverage you have is “creditable”
coverage.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

44

If the coverage from the group plan is “creditable,” it means that it has drug coverage that pays,
on average, at least as much as Medicare’s standard drug coverage.
Keep these notices about creditable coverage, because you may need them later. If you enroll
in a Medicare plan that includes Part D drug coverage, you may need these notices to show that
you have maintained creditable coverage. If you didn’t get a notice about creditable coverage
from your employer or retiree group plan, you can get a copy from the employer or retiree
group’s benefits administrator or the employer or union.

SECTION 10

Chapter 3
Section 10.1

Programs on drug safety and
managing medications

Programs to help members use drugs
safely

We conduct drug use reviews for our members to help make sure that they are getting safe and
appropriate care. These reviews are especially important for members who have more than one
provider who prescribes their drugs.
We do a review each time you fill a prescription. We also review our records on a regular basis.
During these reviews, we look for potential problems such as:
•

Possible medication errors.

•

Drugs that may not be necessary because you are taking another drug to treat the same
medical condition.

•

Drugs that may not be safe or appropriate because of your age or gender.

•

Certain combinations of drugs that could harm you if taken at the same time.

•

Prescriptions written for drugs that have ingredients you are allergic to.

•

Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of medications, we will work with your doctor to
correct the problem.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your Part D prescription drugs

Chapter 3
Section 10.2

45

Programs to help members manage their
medications

We have programs that can help our members with special situations. For example, some
members have several complex medical conditions or they may need to take many drugs at the
same time, or they could have very high drug costs.
These programs are voluntary and free to members. A team of pharmacists and doctors
developed the programs for us. The programs can help make sure that our members are using the
drugs that work best to treat their medical conditions and help us identify possible medication
errors.
If we have a program that fits your needs, we will send you information that tells you what you
need to do to join it. If we do contact you, we hope you will join so that we can help you manage
your medications. Remember, you don’t need to pay anything extra to participate.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

46

CHAPTER 4: What you pay for your Part D prescription drugs

SECTION 1. Introduction
1.1

Use this chapter together with other materials that explain your
drug coverage .........................................................................................................[xx]

SECTION 2. What you pay for a drug depends on which “drug payment
stage” you are in when you get the drug
2.1

What are Medicare’s [insert number of stages] drug payment stages? .................... [xx]

SECTION 3. We send you reports that tell about payments for your drugs
and which payment stage you are in
3.1

We send you a monthly report called the “Explanation of Benefits” ....................... [xx]

3.2

Help us keep our information about your drug payments up-to-date ....................... [xx]

SECTION 4. During the Yearly Deductible Stage, you pay the full cost of
your drugs
4.1

You stay in the Yearly Deductible Stage until you have paid $[insert
deductible] for your drugs ....................................................................................... [xx]

SECTION 5. During the Initial Coverage Stage, the plan pays its
share of your drug costs and you pay your share
5.1

What you pay for a drug depends on the drug and where you fill your
prescription .............................................................................................................[xx]

5.2 A table that shows your costs for a 30-day supply of a drug ...................................[xx]
5.3

A table that shows your costs for a longer-term supply of a drug ...........................[xx]

5.4

You stay in the Initial Coverage Stage until your total drug costs for the year
reach $[insert initial coverage limit] ......................................................................[xx]

SECTION 6. During the Coverage Gap Stage, [insert either: you pay
the full cost of your drugs OR the plan provides limited
drug coverage]
6.1

You stay in the Coverage Gap Stage until your “out-of-pocket” costs reach
$[insert TrOOP] ......................................................................................................[xx]

6.2

How Medicare calculates your “out-of-pocket” costs for your drugs ...................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

47

SECTION 7. During the Catastrophic Coverage Stage, the plans pays most of
the cost for your drugs
7.1

Once you are in the Catastrophic Coverage Stage, you will stay in this stage
for the rest of the year.............................................................................................. [xx]

SECTION 8. Additional benefits information
8.1

Our plan offers additional benefits ..........................................................................[xx]

SECTION 9. What you pay for vaccinations depends on how and
where you get them
9.1

Our plan has separate coverage for the vaccine medication itself and for the
cost of giving you the vaccination shot ..................................................................[xx]

9.2

You may want to call us at Member Services before you get a vaccination ............ [xx]

SECTION 10. Do you have to pay the Part D “late enrollment penalty”?
10.1 What is the Part D late enrollment penalty? ............................................................. [xx]
10.2 How much is the late enrollment penalty?................................................................ [xx]
10.3 In some situations you can enroll late and not have to pay the penalty .................... [xx]
10.4 What can you do if you disagree about your late enrollment penalty? ..................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

48

[Delete this box if this is your LIS EOC.]
Did you know there are programs to help people pay for
their drugs?
[Insert as appropriate, depending on whether SPAPs are discussed in
Chapter 2: There are programs to help people with limited resources pay
for their drugs. These include “Extra Help” and State Pharmaceutical
Assistance Programs. OR The “Extra Help” program helps people with
limited resources pay for their drugs.] For more information, see Chapter
2, Section 7.
Are you currently getting help to pay for your drugs?
If you are in a program that helps pay for your drugs, some information in
this Evidence of Coverage is not correct for you. Please call Member
Services and ask for the Evidence of Coverage for people who get extra
help paying for drugs. Phone numbers for Member Services are on the
front cover.

SECTION 1

Chapter 4
Section 1.1

Introduction

Use this chapter together with other
materials that explain your drug coverage

This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple,
we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 3,
Section 7.1, some drugs are covered under Original Medicare or are excluded by law. Some
excluded drugs may be covered by our plan if the member purchases supplemental drug
coverage.
To understand the payment information we give you in this chapter, you need to know the basics
of what drugs are covered, where to fill your prescriptions, and what rules to follow when you
get your covered drugs. Here are materials that explain these basics:
•

The plan’s List of Covered Drugs (Formulary). To keep things simple, we call this the
“Drug List.”
o This Drug List tells which drugs are covered for you.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

49

o [Plans that do not use cost groups, omit] It also tells which of the [insert number of
cost groups] “Cost Groups” the drug is in and whether there are any restrictions on
your coverage for the drug.
o If you need a copy of the Drug List, call Member Services (phone numbers are on
the cover of this booklet). You can also find the Drug List on our website at [insert
URL]. The Drug List on the website is always the most current.
•

Chapter 3 of this booklet. Chapter 3 gives the details about your prescription drug
coverage, including rules you need to follow when you get your covered drugs. Chapter 3
also tells which types of prescription drugs are not covered by our plan.

•

The plan’s Pharmacy Directory. In most situations you must use a network pharmacy to
get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list
of pharmacies in the plan’s network and it tells how you can use the plan’s mail order
service to get certain types of drugs. It also explains how you can get a longer-term
supply of a drug (such as filling a prescription for a three month’s supply).

SECTION 2

Chapter 4
Section 2.1

What you pay for a drug depends on
which “drug payment stage” you are in
when you get the drug

What are the [insert number of stages]
drug payment stages?

As shown in the table below, there are [insert number of stages] “drug payment stages” for
your prescription drug coverage. How much you pay for a drug depends on which of these
stages you are in at the time you get a prescription filled or refilled. Keep in mind you are
always responsible for the plan’s monthly premium regardless of the drug payment stage.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

50

[Plans with no deductible should revise the chart as needed to describe their drug coverage
stages.]

You begin in this
payment stage when
you fill your first
prescription of the
year.

The plan pays its
share of the cost of
your drugs and
you pay your
share of the cost.

During this stage
you pay the full
cost of your drugs.

You stay in this
stage until your
payments for the
year plus the
plan’s payments
total $[insert
initial coverage
limit]

You stay in this
stage until you have
paid $[insert
deductible amount]
for your drugs
($[insert deductible
amount] is the
amount of your
deductible).
(Details are in
Section 4 of this
chapter.)

(Details are in
Section [insert as
appropriate: 4 OR
5] of this chapter.)

[Insert either:
You pay the full
cost of your drugs.
OR
The plan will
provide limited
coverage [needs
standardized
terminology for
“limited
coverage”] during
the coverage gap
stage.]

Once you have paid
enough for your
drugs to move on to
this last payment
stage, the plan will
pay most of the cost
of your drugs for the
rest of the year.
(Details are in
Section [insert as
appropriate: 6 OR
7] of this chapter.)

You stay in this
stage until your
“out-of-pocket
costs” reach a total
of $[insert
TrOOP]. This
amount and rules
for counting costs
toward this amount
have been set by
Medicare.
(Details are in
Section [insert as
appropriate: 5 OR
6] of this chapter.)

As shown in this summary of the [insert number of stages] payment stages, whether you move on
to the next payment stage depends on how much you and/or the plan spends for your drugs while
you are in each stage.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

SECTION 3

Chapter 4
Section 3.1

51

We send you reports that tell about
payments for your drugs and which
payment stage you are in

We send you a monthly report called the
“Explanation of Benefits”

Our plan keeps track of the costs of your prescription drugs and the payments you have made
when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you
when you have moved from one drug payment stage to the next. In particular, there are two types
of costs we keep track of:
•

We keep track of how much you pay yourself. This is called your “out-of-pocket”
cost.

•

We keep track of your “total drug costs.” This is the amount you pay out-of-pocket
plus the amount paid by the plan.

At the end of every month when you have had one or more prescriptions filled, we prepare a
written report called the Explanation of Benefits (it is sometimes called the “EOB.”) We mail a
copy of this report to you. It includes:
•

Information for that month. This reports gives the payment details about the
prescriptions you have filled during the previous month. It shows the total drugs costs,
what the plan paid, and what you and others paid.

•

Totals for the year since January 1. This is called “year-to-date” information. It shows
you the total drug costs and total payments for your drugs since the year began.

Chapter 4
Section 3.2

Help us keep our information about your
drug payments up to date

To keep track of your drug costs and the payments you make for drugs, we use records we get
from pharmacies. Here is how you can help us keep your information correct and up to date:
•

Show your membership card when you get a prescription filled. To make sure we
know about the prescriptions you are filling and what you are paying, show your plan
membership card every time you get a prescription filled.

•

Make sure we have the information we need. There are times you may pay for
prescription drugs when we will not automatically get the information we need. To help

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

52

us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs
that you have purchased. (If you are billed for a covered drug, you can ask our plan to
pay our share of the cost. For instructions on how to do this, go to Chapter 7 of this
booklet.) Here are some types of situations when you may want to gives us copies of your
drug receipts to be sure we have a complete record of what you have spent for your
drugs:
o When you purchase a covered drug at a network pharmacy at a special price or
using a discount card that is not part of our plan’s benefit.
o When you made a copayment for drugs that are provided under a drug
manufacturer patient assistance program.
o Any time you have purchased covered drugs at out-of-network pharmacies or
other times you have paid the full price for a covered drug under special
circumstances.
•

Check the written report we send you. When you receive an Explanation of Benefits in
the mail, please look it over to be sure the information is complete and correct. If you
think something is missing from the report, or you have any questions, please call us at
Member Services (phone numbers are on the cover of this booklet). Be sure to keep these
reports. They are an important record of your drug expenses.

SECTION 4

During the Yearly Deductible Stage, you
pay the full cost of your drugs

[Plans with no deductible: Omit Section 4.]
Chapter 4
Section 4.1

You stay in the Yearly Deductible Stage
until you have paid $[insert deductible
amount] for your drugs

The Yearly Deductible Stage is the first payment stage for your drug coverage. This stage begins
when you fill your first prescription in the year. [Plans with a deductible for all drug types/cost
groups, insert: When you are in this payment stage, you must pay the full cost of your drugs
until you reach the plan’s deductible amount, which is $[insert deductible amount] for 2010.]
[Plans with a deductible on only a subset of drugs, insert: You will pay a yearly deductible of
$[insert deductible amount] on [insert applicable drug cost groups] drugs. You must pay the
full cost of your [insert applicable drug cost groups] drugs until you reach the plan’s
deductible amount. For all other drugs you will not have to pay any deductible and will start
receiving coverage immediately.]
•

Your “full cost” is usually lower than the normal full price of the drug, since our plan has
negotiated lower costs for most drugs.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

•

53

The “deductible” is the amount you must pay for your Part D prescription drugs before
the plan begins to pay its share.

Once you have paid $[insert deductible amount] for your drugs, you leave the Yearly Deductible
Stage and move on to the next drug payment stage, which is the Initial Coverage Stage.

SECTION 5

Chapter 4
Section 5.1

During the Initial Coverage Stage, the
plan pays its share of your drug costs
and you pay your share

What you pay for a drug depends on the
drug and where you fill your prescription

During the Initial Coverage Period, the plan pays its share of the cost of your covered
prescription drugs, and you pay your share. Your share of the cost will vary depending on the
drug and where you fill your prescription.
The plan has [insert number of cost groups] Cost Groups
[Plans that do not use drug cost groups should omit this section.]
Every drug on the plan’s Drug List is in one of [insert number of cost groups] Cost Groups. In
general, the higher the Cost Group number, the higher your cost for the drug:
•

[Plans should briefly describe each cost group (e.g., Cost Group 1 includes generic
drugs). Indicate which is the lowest cost group and which is the highest cost group.]

To find out which Cost Group your drug is in, look it up in the plan’s Drug List.
Your pharmacy choices
How much you pay for a drug depends on whether you get the drug from:
•

[Pharmacies with preferred and non-preferred pharmacies, delete this bullet and use
next two bullets instead:] A retail pharmacy that is in our plan’s network

•

[Pharmacies with preferred and non-preferred pharmacies, insert: A preferred pharmacy
that is in our plan’s network]

•

[Pharmacies with preferred and non-preferred pharmacies, insert either: A nonpreferred network pharmacy OR An another network pharmacy]

•

A pharmacy that is not in the plan’s network

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

•

54

[Plans without mail-order service, delete this bullet:] The plan’s mail-order pharmacy

For more information about these pharmacy choices and filling your prescriptions, see Chapter 3
in this booklet and the plan’s Pharmacy Directory.
[Include if plan has both preferred and non-preferred pharmacies in their networks: Preferred
pharmacies are pharmacies in our network where the plan has negotiated lower cost-sharing for
members for covered drugs than at [insert either: non-preferred pharmacies OR other network
pharmacies]. However, you will still have access to lower drug prices at [insert either: nonpreferred pharmacies OR these other network pharmacies] than at out-of-network pharmacies.
You may go to either of these types of network pharmacies to receive your covered prescription
drugs.

Chapter 4
Section 5.2

A table that shows your costs for a 30-day
supply of a drug

[Plans using only copayments or only coinsurance should edit this paragraph to reflect the
plan’s cost-sharing:] During the Initial Coverage Period, your share of the cost of a covered
drug will be either a copayment or coinsurance.
•

“Copayment” means that you pay a fixed amount each time you fill a prescription.

•

“Coinsurance” means that you pay a percent of the total cost of the drug each time you
fill a prescription.

[Plans that do not use drug cost groups, omit:] As shown in the table below, the amount of the
copayment or coinsurance depends on which Cost Group your drug is in.
[If plan has any preferred pharmacies, the chart must be modified to reflect the appropriate
member cost-sharing for preferred and non-preferred pharmacies. The plan may also add or
remove cost groups as necessary.]
[If plan operates nationally or in multiple service areas, the chart may be modified to allow the
option of indicating – either within the chart, or by reference to a separate chart – any variance
in the cost-sharing levels for certain cost groups for plans in different service areas.] [Insert if
applicable: The chart lists information for more than one of our plans. The name of the plan you
are in is listed on the front page of this booklet. If you aren’t sure which plan you are in or if you
have any questions, call Member Services.]
Your share of the cost when you get a 30-day supply (or less) of a covered
Part D prescription drug from:

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

55

Out-of-network
pharmacy

Cost Group 1
([insert description,
e.g., “generic
drugs”])

Cost Group 2
([insert description])

Cost Group 3
([insert description])

Cost Group 4
([insert description])

Chapter 4
Section 5.3

(coverage is limited
to certain situations;
see Chapter 3 for
details)

Network
pharmacy

The plan’s
mail-order
service

Network
long-term care
pharmacy

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

A table that shows your copayments for a
longer-term [insert number of days] supply
of a drug

For some drugs, you can get a longer-term supply (also called an “extended supply”) when you
fill your prescription. This can be up to a [insert number of days] supply. (For details on where
and how to get a longer-term supply of a drug, see Chapter 5.)
The table below shows what you pay when you get a longer-term [insert number of days]
supply of a drug.
[If plan has any preferred pharmacies, the chart must be modified to reflect the appropriate
member cost-sharing for preferred and non-preferred pharmacies. The plan may also add or
remove cost groups as necessary.]
[If plan operates nationally or in multiple service areas, the chart may be modified to allow the
option of indicating – either within the chart, or by reference to a separate chart – any

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

56

variance in the cost-sharing levels for certain cost groups for plans in different service areas.]
[Insert if applicable: The chart lists information for more than one of our plans. The name of
the plan you are in is listed on the front page of this booklet. If you aren’t sure which plan you
are in or if you have any questions, call Member Services.]
Your share of the cost when you get a longer-term [insert number
of days] supply of a covered Part D prescription drug from:

Cost Group 1
([insert description])

Cost Group 2
([insert
description])

Cost Group 3
([insert description])

Cost Group 4
([insert description])

Chapter 4
Section 5.4

Network pharmacy

The plan’s mail-order service

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

You stay in the Initial Coverage Stage
until your total drug costs for the year
reach $[insert initial coverage limit]

You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have
filled and refilled reaches the $[insert initial coverage limit] limit for the Initial Coverage
Stage.
Your total drug cost is based on adding together what you have paid and what the plan has paid:
• What you have paid for all the covered drugs you have gotten since you started with
your first drug purchase of the year. (see Section 6.2 for more information about how
Medicare calculates your out-of-pocket costs) This includes:
o

[Plans without a deductible, omit:] The $[insert deductible amount] you paid when
you were in the Yearly Deductible Stage.

o The total you paid as your share of the cost for your drugs during the Initial
Coverage Stage.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

57

• What the plan has paid as its share of the cost for your drugs during the Initial
Coverage Stage.
[Insert if applicable: We offer additional coverage on some prescription drugs that are not
normally covered in a Medicare Prescription Drug Plan. Payments made for these drugs will not
count towards your initial coverage limit or total out-of-pocket costs. [Insert only if plan pays for
OTC drugs as part of its administrative costs: We also provide some over-the-counter
medications exclusively for your use. These over-the-counter drugs are provided at no cost to
you.] To find out which drugs our plan covers, refer to your formulary.]
The Explanation of Benefits that we send to you will help you keep track of how much you and
the plan have spent for your drugs during the year. Many people do not reach the $[insert initial
coverage limit] limit in a year.
We will let you know if you reach this $[insert initial coverage limit] amount. If you do reach
this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage.

SECTION 6

Chapter 4
Section 6.1

During the Coverage Gap Stage, [insert as
appropriate: you pay the full cost of your
drugs OR the plan provides limited drug
coverage]

You stay in the Coverage Gap Stage until
your out-of-pocket costs reach $[insert
TrOOP amount]

Once your total out-of-pocket costs reach $[insert TrOOP amount], you will qualify for
catastrophic coverage.
[Plans without any gap coverage, insert: When you are in the coverage gap stage, you pay the
full cost for your drugs. (Your full cost is usually lower than the normal full price of the drug,
since our plan has negotiated lower costs for most drugs.) You continue paying the full cost until
your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2010,
that amount is $[insert TrOOP amount].]
[Plans offering some gap coverage, insert: After you leave the Initial Coverage Stage, we will
continue to provide some prescription drug coverage until your yearly out-of-pocket costs reach
a maximum amount that Medicare has set. In 2010, that amount is $[insert TrOOP amount].
[Plans offering coverage in the coverage gap must describe that coverage: must be consistent
with the standard terminology used for the Summary of Benefits]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

58

Medicare has rules about what counts and what does not count as your out-of-pocket costs.
When you reach an out-of-pocket limit of $[insert TrOOP amount], you leave the Coverage Gap
Stage and move on to the Catastrophic Coverage Stage.

Chapter 4
Section 6.2

How Medicare calculates your out-of-pocket
costs for prescription drugs

Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs
for your drugs.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

59

These payments are included in
your out-of-pocket costs
When you add up your out-of-pocket costs, you can include the payments listed below (as
long as they are for Part D covered drugs and you followed the rules for drug coverage that
are explained in Chapter 5 of this booklet):
• The amount you pay for drugs when you are in any of the following drug payment
stages:
o [Plans without a deductible, omit:] The Yearly Deductible Stage.
o The Initial Coverage Stage.
o The Coverage Gap Stage.
• Any payments you made during this calendar year under another Medicare prescription
drug plan before you joined our plan.
It matters who pays:
• If you make these payments yourself, they are included in your out-of-pocket costs.
• These payments are also included if they are made on your behalf by certain other
individuals or organizations. This includes payments for your drugs made by a friend
or relative, by most charities, or by a State Pharmaceutical Assistance Program that is
qualified by Medicare. Payments made by “Extra Help” from Medicare are also
included.
Moving on to the Catastrophic Coverage Stage:
When you (or those paying on your behalf) have spent a total of $[insert TrOOP amount] in
out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to
the Catastrophic Coverage Stage.

These payments are not included
in your out-of-pocket costs
When you add up your out-of-pocket costs, you are not allowed to include any of these
types of payments for prescription drugs:
• [Plans with no premium, omit:] The amount you pay for your monthly premium.
• Drugs you buy outside the United States and its territories.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

60

• Drugs that are not covered by our plan.

• Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements
for out-of-network coverage.
• [Insert if plan does not provide coverage for excluded drugs as a supplemental benefit:
Non-Part D drugs, including prescription drugs covered by Part A or Part B and other
drugs excluded from coverage by Medicare.]
[Insert next two bullets if plan provides coverage for excluded drugs as a supplemental benefit.
• Prescription drugs covered by Part A or Part B.
• Payments you make toward drugs covered under our additional coverage but not
normally covered in a Medicare Prescription Drug Plan.]
• [Insert if applicable: Payments you make toward prescription drugs not normally
covered in a Medicare Prescription Drug Plan.]
• Payments for your drugs that are made by group health plans including employer health
plans.
• Payments for your drugs that are made by insurance plans and government-funded
health programs such as TRICARE, the Veteran’s Administration, the Indian Health
Service, or AIDS Drug Assistance Programs.
• Payments for your drugs made by a third-party with a legal obligation to pay for
prescription costs (for example, Worker’s Compensation).
Reminder: If any other organization such as the ones listed above pays part or all of your
out-of-pocket costs for drugs, you are required to tell our plan. Call Member Services to let
us know (phone numbers are on the cover of this booklet).

How can you keep track of your out-of-pocket total?
• We will help you. The Explanation of Benefits report we send to you includes the
current amount of your out-of-pocket costs (Section 3 above tells about this report).
When you reach a total of $[insert TrOOP amount] in out-of-pocket costs for the year,
this report will tell you that you have left the Coverage Gap Stage and have moved on to
the Catastrophic Coverage Stage.
• Make sure we have the information we need. Section 3 above tells what you can do to
help make sure that our records of what you have spent are complete and up to date.

SECTION 7

During the Catastrophic Coverage Stage,
the plan pays most of the cost for your
drugs

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

Chapter 4
Section 7.1

61

Once you are in the Catastrophic
Coverage Stage, you will stay in this
stage for the rest of the year

You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the
$[insert TrOOP amount] limit for the calendar year. Once you are in the Catastrophic Coverage
Stage, you will stay in this payment stage until the end of the calendar year.
During this stage, the plan will pay most of the cost for your drugs.
[Plans insert appropriate option for your catastrophic cost sharing.
Option 1:
•

Your share of the cost for a covered drug will be either coinsurance or a copayment,
whichever is the larger amount:
o –either – coinsurance of 5% of the cost of the drug
o –or –

•

$[Insert 2010 catastrophic cost-sharing amount for
generics/preferred multisource drugs] copayment for a
generic drug or a drug that is treated like a generic. Or a
$[Insert 2009 catastrophic cost-sharing amount for all other
drugs] copayment for all other drugs.

Our plan pays the rest of the cost.

Option 2:
[Insert appropriate tiered cost-sharing amounts]. We will pay the rest.

SECTION 8

Chapter 4
Section 8.1

Additional benefits information

Our plan offers additional benefits

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

62

[Optional: Insert any additional benefits information based on the plan’s approved bid that is
not captured in the sections above.]

SECTION 9

Chapter 4
Section 9.1

What you pay for vaccinations depends
on how and where you get them

Our plan has coverage for the vaccine
medication itself and for the cost of
giving you the vaccination shot

Our plan provides coverage of a number of vaccines. There are two parts to our coverage of
vaccinations:
•

The first part of coverage is the cost of the vaccine medication itself. The vaccine is a
prescription medication.

•

The second part of coverage is for the cost of giving you the vaccination shot. (This is
sometimes called the “administration” of the vaccine.)

What do you pay for a vaccination?
What you pay for a vaccination depends on three things:
1. The type of vaccine (what you are being vaccinated for).
o Some vaccines are considered Part D drugs. You can find these vaccines listed in
the plan’s List of Covered Drugs.
2. Where you get the vaccine medication.
3. Who gives you the vaccination shot.
What you pay at the time you get the vaccination can vary depending on the circumstances. For
example:
•

Sometimes when you get your vaccination shot, you will have to pay the entire cost for
both the vaccine medication and for getting the vaccination shot. You can ask our plan to
pay you back for our share of the cost.

•

Other times, when you get the vaccine medication or the vaccination shot, you will pay
only your share of the cost.

To show how this works, here are three common ways you might get a vaccination shot. [Insert
if applicable: Remember you are responsible for all of the costs associated with vaccines

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

63

(including their administration) during the [insert as applicable: Deductible Stage OR Coverage
Gap Stage OR Deductible and Coverage Gap Stage] of your benefit.]
Situation 1:

You buy the vaccine at the pharmacy and you get your vaccination shot at the
network pharmacy. (Whether you have this choice depends on where you live.
Some states do not allow pharmacies to administer a vaccination.)
• You will have to pay the pharmacy the amount of your [insert as
appropriate: copayment OR coinsurance] for the vaccine and
administration of the vaccine.

Situation 2:

You get the vaccination at your doctor’s office.
• When you get the vaccination, you will pay for the entire cost of the
vaccine and its administration.
• You can then ask our plan to pay our share of the cost by using the
procedures that are described in Chapter 5 of this booklet (Asking the
plan to pay its share of a bill you have received for medical services or
drugs).
• You will be reimbursed the amount you paid less your normal [insert
as appropriate: coinsurance OR copayment] for the vaccine (including
administration) [Insert the following only if an out-of-network
differential is charged: less any difference between the amount the
doctor charges and what we normally pay. (If you are in the Extra
Help program, we will reimburse you for this difference.)]

Situation 3:

You buy the vaccine at your pharmacy, and then take it to your doctor’s office
where they give you the vaccination shot.
• You will have to pay the pharmacy the amount of your [insert as
appropriate: coinsurance OR copayment] for the vaccine itself.
• When your doctor gives you the vaccination shot, you will pay the
entire cost for this service. You can then ask our plan to pay our share
of the cost by using the procedures described in Chapter 5 of this
booklet.
• You will be reimbursed the amount charged by the doctor less the
amount we will pay for administering the vaccine [Insert the following
only if an out-of-network differential is charged: less any difference
between the amount the doctor charges and what we normally pay. (If
you are in the Extra Help program, we will reimburse you for this
difference.)]

[Insert any additional information about your coverage of vaccines and vaccine administration.]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

Chapter 4
Section 9.2

64

You may want to call us at Member Services
before you get a vaccination

The rules for coverage of vaccinations are complicated. We are here to help. We recommend that
you call us first at Member Services whenever you are planning to get a vaccination (phone
numbers are on the cover of this booklet).
•

We can tell you about how your vaccination is covered by our plan and explain your
share of the cost.

•

We can tell you how to keep your own cost down by using providers and pharmacies in
our network.

•

If you are not able to use a network provider and pharmacy, we can tell you what you
need to do to get payment from us for our share of the cost.

SECTION 10

Chapter 4
Section 10.1

Do you have to pay the Part D “late
enrollment penalty”?

What is the Part D “late enrollment
penalty”?

You may pay a financial penalty if you did not enroll in a plan offering Medicare Part D
drug coverage when you first became eligible for this drug coverage or you experienced a
continuous period of 63 days or more when you didn’t keep your prescription drug
coverage. The amount of the penalty depends on how long you waited before you enrolled
in drug coverage after you became eligible or how many months after 63 days you went
without drug coverage.
The penalty is added to your monthly premium. (Members who choose to pay their premium
every three months will have the penalty added to their three-month premium.) When you
first enroll in [insert plan name], we let you know the amount of the penalty.

Chapter 4
Section 10.2

How much is the Part D late enrollment
penalty?

Medicare determines the amount of the penalty. Here is how it works:

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

65

•

First count the number of full months that you delayed enrolling in a Medicare drug plan,
after you were eligible to enroll. Or count the number of full months in which you had a
break in prescription drug coverage, if the break in coverage was 63 days or more. The
penalty is 1% for every month that you didn’t have creditable coverage. For our example,
let’s say it is 14 months without coverage, which will be 14%

•

Then Medicare determines the amount of the average monthly premium for Medicare
drug plans in the nation from the previous year. [Insert EITHER: For 2010, this average
premium amount is $[insert 2010 national base beneficiary premium] OR For 2009, this
average premium amount was $[insert 2009 national base beneficiary premium]. This
amount may change for 2010.]

•

You multiply together the two numbers to get your monthly penalty and round it to the
nearest 10 cents. In the example here it would be 14% times $[insert base beneficiary
premium], which equals $[insert amount], which rounds to $[insert amount]. This amount
would be added to your monthly premium.

There are three important things to note about this monthly premium penalty:
•

First, the penalty will change each year, because the average monthly premium can
change each year. If the national average premium (as determined by Medicare)
increases, your penalty will increase.

•

Second, you will continue to pay a penalty every month for as long as you are enrolled
in a plan that has Medicare Part D drug benefits.

•

Third, if you are under 65 and currently receiving Medicare benefits, the late enrollment
penalty will reset when you turn 65. After age 65, your late enrollment penalty will be
based only on the months that you don’t have coverage after your initial enrollment into
Medicare.

Chapter 4
Section 10.3

In some situations, you can enroll late and
not have to pay the penalty

Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were
first eligible, sometimes you do not have to pay the late enrollment penalty.
You will not have to pay a premium penalty for late enrollment if you are in any of these
situations:
•

You already have prescription drug coverage at least as good as Medicare’s standard drug
coverage. Medicare calls this “creditable drug coverage.” Creditable coverage could
include drug coverage from a former employer or union, TRICARE, or the Department
of Veterans Affairs. Speak with your insurer or your human resources department to find
out if your current drug coverage is as at least as good as Medicare’s.

•

If you were without creditable coverage, you can avoid paying the late enrollment penalty
if you were without it for less than 63 days.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: What you pay for your Part D prescription drugs

66

•

If you didn’t receive enough information to know whether or not your previous drug
coverage was creditable.

•

You lived in an area affected by Hurricane Katrina at the time of the hurricane (August
2005) – and – you signed up for a Medicare prescription drug plan by December 31,
2006 – and – you have stayed in a Medicare prescription drug plan.

•

You are receiving “Extra Help”.

Chapter 4
Section 10.4

What can you do if you disagree about
your late enrollment penalty?

If you disagree about your late enrollment penalty, you can ask us to review the decision about
your late enrollment penalty. Call Member Services at the number on the front of this booklet to
find out more about how to do this.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of the costs for covered drugs

66

CHAPTER 5: Asking the plan to pay its share of the costs for covered
drugs

SECTION 1. Situations in which you should ask our plan to pay our share of the
cost of your covered drugs
1.1

If you pay our plan’s share of the cost for your covered drugs, you can ask
us for payment ......................................................................................................... [xx]

SECTION 2. How to ask us to pay you back
2.1

How and where to send us your request for payment ............................................. [xx]

SECTION 3. We will consider your request for payment and say yes or no
3.1

We check to see whether we should cover the drug and how much we owe .......... [xx]

3.2

If we tell you that we will not pay for the drug, you can make an appeal .............. [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of the costs for covered drugs

SECTION 1

Chapter 5
Section 1.1

67

Situations in which you should ask our
plan to pay our share of the cost of your
covered drugs

If you pay our plan’s share of the cost for
your covered drugs, you can ask us for
payment

Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other
times, you may find that you have paid more than you expected under the coverage rules of the
plan. In either case, you can ask our plan to pay you back (paying you back is often called
“reimbursing” you). Asking for reimbursement in the first three examples below are types of
coverage decisions (for more information about coverage decisions, go to Chapter 7 of this
booklet).
Here are examples of situations in which you may need to ask our plan to pay you back:
1. When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy and try to use your membership card to fill a
prescription, the pharmacy may not be able to submit the claim directly to us. When that
happens, you will have to pay the full cost of your prescription.
•

Save your receipt and send a copy to us when you ask us to pay you back the difference
between the amount you paid and the amount you owed under the plan.

2. When you pay the full cost for a prescription because you don’t have
your plan membership card with you
If you do not have your plan membership card with you when you fill a prescription at a
network pharmacy, you may need to pay the full cost of the prescription yourself. The
pharmacy can usually call the plan to get your member information, but there may be times
when you may need to pay if you do not have your card.
•

Save your receipt and send a copy to us when you ask us to pay you back the difference
between the amount you paid and the amount you owed under the plan.

3. When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not covered
for some reason.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of the costs for covered drugs

68

•

For example, the drug may not be on the plan’s List of Covered Drugs (Formulary); or
it could have a requirement or restriction that you didn’t know about or don’t think
should apply to you. If you decide to get the drug immediately, you may need to pay
the full cost for it.

•

Save your receipt and send a copy to us when you ask us to pay you back. In some
situations, we may need to get more information from your doctor in order to pay you
back the difference between the amount you paid and the amount you owed under the
plan.

•
4. [Plans not eligible for auto-enrollments, delete this section.] If you are
retroactively enrolled in our plan because you were eligible for
Medicaid.
Medicaid is a joint Federal and state government program that helps with medical costs for
some people with limited incomes and resources. Some people with Medicaid are
automatically enrolled in our plan to get their prescription drug coverage. Sometimes a
person’s enrollment in the plan is retroactive. (Retroactive means that the first day of their
enrollment has already past. The enrollment date may even have occurred last year.)
If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your
drugs after your enrollment date, you can ask us to pay you back for our share of the costs.
You will need to submit your paperwork to a special plan that will handle the reimbursement.
[I’m not sure what the procedure is?]
•

Send a copy of your receipts to us when you ask us to pay you back.

•

You should ask for payment for your out-of-pocket expenses (not for any expenses paid
for by other insurance).

•

You have a 7-month period that allows us to cover most drugs you received between
your enrollment date and the current time. Depending on your situation, either you or
Medicare will need to pay for any out-of-network price differences.

•

The plan may not pay for drugs that are not on our drug list that you received outside of
the 7-month period.

[Plans should insert additional circumstances under which they will accept a paper claim from
an enrollee.]
Here are two other situations when you should send us receipts to let us know about payments
you have made for your drugs:
1. When you buy the drug for a price that is lower than the plan’s price

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of the costs for covered drugs

69

Sometimes when you are in the Coverage Gap Stage you can buy your drug at a network
pharmacy for a price that is lower than the plan's price. Unless special conditions apply, the
pharmacy must be within the plan’s network and the drug must be a covered Part D drug.
•

For example, a pharmacy might offer a special price on the drug. Or you may have a
discount card that is outside the plan’s benefit that offers a lower price.

•

Save your receipt and send a copy to us so that we can have your out-of-pocket
expenses count toward qualifying you for the Catastrophic Coverage Stage.

•

Please note: Because you are in the Coverage Gap Stage [insert if applicable: or
Deductible Stage], the plan will not pay for any share of these drug costs. But sending
the receipt allows us to calculate your out-of-pocket costs correctly and may help you
qualify for the Catastrophic Coverage Stage more quickly.

2. When you get a drug through a patient assistance program offered by a
drug manufacturer
Some members are enrolled in a patient assistance program offered by a drug manufacturer
that is outside the plan benefits. If you get any drugs through a program offered by a drug
manufacturer, you may pay a copayment to the patient assistance program.
•

Save your receipt and send a copy to us so that we can have your out-of-pocket
expenses count toward qualifying you for the Catastrophic Coverage Stage.

•

Please note: Because you are getting your drug through the patient assistance program
and not through the plan’s benefits, the plan will not pay for any share of these drug
costs. But sending the receipt allows us to calculate your out-of-pocket costs correctly
and may help you qualify for the Catastrophic Coverage Stage more quickly.

SECTION 2

Chapter 5
Section 2.1

How to ask us to pay you back

How and where to send us your request
for payment

Send us your request for payment, along with your receipt documenting the payment you have
made. It’s a good idea to make a copy of your receipts for your records.
[If the plan has developed a specific form for requesting payment, insert the following language:
To make sure you are giving us all the information we need to make a decision, you can fill out
our claim form to make your request for payment.
•

You don’t have to use the form, but it’s helpful.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of the costs for covered drugs

•

70

Either download a copy of the form from our website ([insert URL]) or call Member
Services and ask for the form. The phone numbers for Member Services are on the cover
of this booklet.]

Mail your request for payment together with any receipts to us at this address:
[insert address]
Please be sure to contact Member Services if you have any questions. If you don’t know what
you owe, we can help. You can also call if you want to give us more information about a request
for payment you have already sent to us.

SECTION 3

Chapter 5
Section 3.1

We will consider your request for
payment and say yes or no

We check to see whether we should cover
the drug and how much we owe

When we receive your request for payment, we will let you know if we need any additional
information from you. Otherwise, we will consider your request and decide whether to pay it and
how much we owe.
•

If we decide that the drug is covered and you followed all the rules for getting the drug,
we will pay for our share of the cost. We will mail your reimbursement of all but your
share to you. (Chapter 3 explains the rules you need to follow for getting your Part D
prescription drugs.)

•

If we decide that the drug is not covered, or you did not follow all the rules, we will not
pay for our share of the cost. Instead, we will send you a letter that explains the reasons
why we are not sending the payment you have requested, and what your rights are to
appeal that decision.

Chapter 5
Section 3.2

If we tell you that we will not pay for the
drug, you can make an appeal

If you think we have made a mistake in turning you down, you can make an appeal. If you make
an appeal, it means you are asking us to change the decision we made when we turned down
your request for payment. The examples of situations in which you may need to ask our plan to
pay you back:

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Asking the plan to pay its share of the costs for covered drugs

•

When you use an out-of-network pharmacy to get a prescription filled

•

When you pay the full cost for a prescription because you don’t have your plan
membership card with you

•

When you pay the full cost for a prescription in other situations

71

For the details on how to make this appeal, go to Chapter 7 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is
a legal process with detailed procedures and important deadlines. If making an appeal is new to
you, you will find it helpful to start by reading Section 4 of Chapter 7. Section 4 is an
introductory section that explains the process for coverage decisions and appeals and gives
definitions of terms such as “appeal.” Then after you have read Section 4, you can go to the
Section 5 in Chapter 7 for a step-by-step explanation of how to file an appeal.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

71

CHAPTER 6: Your rights and responsibilities

SECTION 1. Our plan must honor your rights as a member of the plan
1.1

We must provide information in a way that works for you (in languages other
than English that are spoken in the plan service area, in large print or other
alternate formats, etc.) ............................................................................................. [xx]

1.2

We must treat you with fairness and respect at all times .......................................... [xx]

1.3

We must ensure that you get timely access to your covered drugs .......................... [xx]

1.4

We must protect the privacy of your personal health information ........................... [xx]

1.5

We must give you information about the plan, its network of pharmacies, and
your covered services .............................................................................................. [xx]

1.6

We must support your right to make decisions about your care ............................... [xx]

1.7 You have the right to make complaints and to ask us to reconsider
decisions we have made .......................................................................................... [xx]
1.8

What can you do if you think you are being treated unfairly or your
rights are not being respected? ................................................................................ [xx]

1.9

How to get more information about your rights ....................................................... [xx]

SECTION 2. You have some responsibilities as a member of the plan
2.1

What are your responsibilities? ................................................................................. [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

SECTION 1

Chapter 6
Section 1.1

72

Our plan must honor your rights as a
member of the plan

We must provide information in a way
that works for you (in languages other
than English that are spoken in our plan
service area, in large print, or other
alternate formats, etc.)

To get information from us in a way that works for you, please call Member Services (phone
numbers are on the front cover).
Our plan has people and translation services available to answer questions from non-English
speaking members. We can also give you information in large print or other alternate formats
(for example, Braille) if you need it. If you are eligible for Medicare because of disability, we
are required to give you information about the plan’s benefits that is accessible and appropriate
for you.
If you have any trouble getting information from our plan because of problems related to
language or disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users call 1-877-486-2048.

Chapter 6
Section 1.2

We must treat you with fairness and
respect at all times

Our plan must obey laws that protect you from discrimination or unfair treatment. We do not
discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed (beliefs),
age, or national origin.
If you want more information or have concerns about discrimination or unfair treatment, please
call the Federal government’s Office for Civil Rights 1-800-368-1019 (TTY/TDD 1-800-5377697) or your local Office for Civil Rights.
If you have a disability and need help with access to care, please call us at Member Services
(phone numbers are on the cover of this booklet). If you have a complaint, such as a problem
with wheelchair access, Member Services can help.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

Chapter 6
Section 1.3

73

We must ensure that you get timely
access to your covered drugs

As a member of our plan, you also have the right to get your prescriptions filled or refilled at any
of our network pharmacies without long delays. If you think that you are not getting your Part D
drugs within a reasonable amount of time, Chapter 7 of this booklet tells what you can do.

Chapter 6
Section 1.4

We must protect the privacy of your
personal health information

Federal and state laws protect the privacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
•

Your “personal health information” includes the personal information you gave us when
you enroll in this plan as well as your medical records and other medical and health
information.

•

The laws that protect your privacy give you rights related to getting information and
controlling how your health information is used. We give you a written notice that tells
about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information?
•

We make sure that unauthorized people don’t see or change your records.

•

In most situations, if we give your health information to anyone who isn’t providing your
care or paying for your care, we are required to get written permission from you first.
Written permission can be given by you or by someone you have given legal power to
make decisions for you.

•

There are certain exceptions that do not require us to get your written permission first.
These exceptions are allowed or required by law.
o For example, we are required to release health information to government
agencies that are checking on quality of care.
o Because you are a member of our plan through Medicare, we are required to give
Medicare your health information including information about your Part D
prescription drugs. If Medicare releases your information for research or other
uses, this will be done according to Federal statutes and regulations.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

74

You can see the information in your records and know how it
has been shared with others
You have the right to look at your medical records held at the plan, and to get a copy of your
records. We are allowed to charge you a fee for making copies. You also have the right to ask us
to make additions or corrections to your medical records. If you ask us to do this, we will
consider your request and decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please
call Member Services (phone numbers are on the cover of this booklet).
[Note: Plans may insert custom privacy practices.]

Chapter 6
Section 1.5

We must give you information about the
plan, its network of pharmacies, and your
covered drugs

As a member of our plan, you have the right to get several kinds of information from us. (As
explained above in Section 1.1, you have the right to get information from us in a way that works
for you. This includes getting the information in languages other than English and in large print
or other alternate formats.)
If you want any of the following kinds of information, please call Member Services (phone
numbers are on the cover of this booklet):
•

Information about our plan. This includes, for example, information about the plan’s
financial condition. It also includes information about the plan’s performance ratings,
including how it has been rated by plan members and how it compares to other Medicare
prescription drug plans.

•

Information about our network pharmacies.
o For example, you have the right to get information from us about the pharmacies
in our network.
o For a list of the pharmacies in the plan’s network, see the Pharmacy Directory.
o For more detailed information about our pharmacies, you can call Member
Services (phone numbers are on the cover of this booklet) or visit our website at
[insert URL].

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

•

75

Information about your coverage and rules you must follow in using your
coverage.
o To get the details on your Part D prescription drug coverage, see Chapters 3 and 4
of this booklet plus the plan’s List of Covered Drugs (Formulary). These chapters,
together with the List of Covered Drugs, tell you what drugs are covered and
explain the rules you must follow and the restrictions to your coverage for certain
drugs.
o If you have questions about the rules or restrictions, please call Member Services
(phone numbers are on the cover of this booklet).

•

Information about why something is not covered and what you can do
about it.
o If a Part D drug is not covered for you, or if your coverage is restricted in some
way, you can ask us for a written explanation. You have the right to this
explanation even if you received the drug from an out-of-network pharmacy.
o If you are not happy or if you disagree with a decision we make about what Part
D drug is covered for you, you have the right to ask us to change the decision. For
details on what to do if something is not covered for you in the way you think it
should be covered, see Chapter 7 of this booklet. It gives you the details about
how to ask the plan for a decision about your coverage and how to make an
appeal if you want us to change our decision. (Chapter 7 also tells about how to
make a complaint about quality of care, waiting times, and other concerns.)
o If you want to ask our plan to pay our share of the cost for a Part D prescription
drug, see Chapter 5 of this booklet.

Chapter 6
Section 1.6

We must support your right to make
decisions about your care

You have the right to give instructions about what is to be done
if you are not able to make medical decisions for yourself
Sometimes people become unable to make health care decisions for themselves due to accidents
or serious illness. You have the right to say what you want to happen if you are in this situation.
This means that, if you want to, you can:
•

Fill out a written form to give someone the legal authority to make medical decisions
for you if you ever become unable to make decisions for yourself.

•

Give your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are
called “advance directives.” There are different types of advance directives and different names

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

76

for them. Documents called “living will” and “power of attorney for health care” are examples
of advance directives.
If you want to use an “advance directive” to give your instructions, here is what to do:
•

Get the form. If you want to have an advance directive, you can get a form from your
lawyer, from a social worker, or from some office supply stores. You can sometimes get
advance directive forms from organizations that give people information about Medicare.
[Insert if applicable: You can also contact Member Services to ask for the forms (phone
numbers are on the cover of this booklet).]

•

Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a
legal document. You should consider having a lawyer help you prepare it.

•

Give copies to appropriate people. You should give a copy of the form to your doctor
and to the person you name on the form as the one to make decisions for you if you can’t.
You may want to give copies to close friends or family members as well. Be sure to keep
a copy at home.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance
directive, take a copy with you to the hospital.
•

If you are admitted to the hospital, they will ask you whether you have signed an advance
directive form and whether you have it with you.

•

If you have not signed an advance directive form, the hospital has forms available and
will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including
whether you want to sign one if you are in the hospital). According to law, no one can deny you
care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed
the instructions in it, you may file a complaint with [insert appropriate state-specific agency
(such as the State Department of Health)]. [Note: Plans that would like to provide members with
state specific information about advanced directives may do so.]

Chapter 6
Section 1.7

You have the right to make complaints
and to ask us to reconsider decisions we
have made

If you have any problems or concerns about your covered services or care, Chapter 7 of this
booklet tells what you can do. It gives the details about how to deal with all types of problems
and complaints.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

77

As explained in Chapter 7, what you need to do to follow up on a problem or concern depends on
the situation. You might need to ask our plan to make a coverage decision for you, make an
appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a
coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.
You have the right to get a summary of information about the appeals and complaints that other
members have filed against our plan in the past. To get this information, please call Member
Services (phone numbers are on the cover of this booklet).

Chapter 6
Section 1.8

What can you do if you think you are
being treated unfairly or your rights are
not being respected?

If it is about discrimination, call the Office for Civil Rights
If you think you have been treated unfairly or your rights have not been respected due to your
race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should
call the Department of Health and Human Services’ Office for Civil Rights at 1-800-3681019 or TTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you think you have been treated unfairly or your rights have not been respected, and it’s not
about discrimination, you can get help dealing with the problem you are having:

• You can call Member Services (phone numbers are on the cover of this booklet).
• You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, turn to Chapter 2 of this booklet and look for Section
3.

Chapter 6
Section 1.9

How to get more information about your
rights

There are several places where you can get more information about your rights:

• You can call Member Services (phone numbers are on the cover of this booklet).
• You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, turn to Chapter 2 of this booklet and look for Section
3.

• You can contact Medicare.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

78

o You can visit www.medicare.gov/Publications/Pubs/pdf/10122.pdf to read or
download the publication “Your Medicare Rights & Protections.”
o Or, you can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.

SECTION 2

Chapter 6
Section 2.1

Your responsibilities as a
member of the plan

What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services (phone numbers are on the cover of this booklet). We’re here to
help.
•

Get familiar with your covered drugs and the rules you must follow to get
these covered drugs. Use this Evidence of Coverage booklet to learn what is
covered for you and the rules you need to follow to get your covered drugs.
o Chapters 3 and 4 give the details about your coverage for Part D prescription
drugs.

•

If you have any other prescription drug coverage besides our plan, you are
required to tell us. Please call Member Services to let us know.
o We are required to follow rules set by Medicare to make sure that you are using
all of your coverage in combination when you get your covered drugs from our
plan. This is called “coordination of benefits” because it involves coordinating
the drug benefits you get from our plan with any other drug benefits available to
you. We’ll help you with it.

•

Tell your doctor and pharmacist that you are enrolled in our plan. Show your
plan membership card whenever you get your Part D prescription drugs.

•

Help your doctors and other providers help you by giving them
information, asking questions, and following through on your care.
o To help your doctors and other health providers give you the best care, give them
the information they need about you and your health. Follow the treatment plans
and instructions that you and your doctors agree upon.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: Your rights and responsibilities

79

o If you have any questions, be sure to ask. Your doctors and other health care
providers are supposed to explain things in a way you can understand. If you ask
a question and you don’t understand the answer you are given, ask again.
•

Pay what you owe. As a plan member, you are responsible for these payments:
o [Insert if applicable: You must pay your plan premiums to continue being a
member of our plan.]
o For some of your drugs covered by the plan, you must pay your share of the cost
when you get the drug. This will be a [insert as appropriate: copayment (a fixed
amount) OR coinsurance (a percentage of the total cost)] Chapter 4 tells what you
must pay for your Part D prescription drugs.
o If you get any drugs that are not covered by our plan or by other insurance you
may have, you must pay the full cost.

•

Tell us if you move. If you are going to move, it’s important to tell us right away.
Call Member Services (phone numbers are on the cover of this booklet).
o If you move outside of our plan service area, you [if a continuation area is
offered, insert “generally” here and then explain the continuation area] cannot
remain a member of our plan. (Chapter 1 tells about our service area.) We can
help you figure out whether you are moving outside our service area. If you are
leaving our service area, we can let you know if we have a plan in your new area.
o If you move within our service area, we still need to know so we can keep your
membership record up to date and know how to contact you.

•

Call member services for help if you have questions or concerns. We also
welcome any suggestions you may have for improving our plan.
o Phone numbers and calling hours for Member Services are on the cover of this
booklet.
o For more information on how to reach us, including our mailing address, please
see Chapter 2 of this booklet.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 80

CHAPTER 7: What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
Background
SECTION 1. Introduction
1.1

What to do if you have a problem or concern ........................................................[xx]

1.2

What about the legal terms? .................................................................................... [xx]

SECTION 2. You can get help from government organizations that
are not connected with our plan
2.1

Where to get more information and personalized assistance .................................[xx]

SECTION 3. To deal with your problem, which process should you use?
3.1

Should you use the process for coverage decisions and appeals? Or should
you use the process for making complaints? ........................................................... [xx]

Coverage decisions and appeals
SECTION 4. A guide to the basics of coverage decisions and appeals
4.1

Asking for coverage decisions and making appeals: the big picture ...................... [xx]

4.2

How to get help when you are asking for a coverage decision or making an
appeal.......................................................................................................................[xx]

4.3

Which section of this chapter gives the details for your situation? ......................... [xx]

SECTION 5. Your Part D prescription drugs: How to ask for a
coverage decision or make an appeal
5.1

This section tells what to do if you have problems getting a Part D drug
or you want us to pay you back for a Part D drug ..................................................[xx]

5.2

What kinds of exceptions to the coverage rules can you ask for? ........................... [xx]

5.3

Important things to know about asking for exceptions to the
rules for coverage of Part D drugs ..........................................................................[xx]

5.4

Step-by-step: How to ask for a coverage decision (how to ask
our plan to make an exception for you) ................................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 81

5.5

Step-by-step: How to make a Level 1 Appeal (how to ask for a review of
a coverage decision made by our plan) ................................................................... [xx]

5.6

Step-by-step: How to make a Level 2 Appeal ......................................................... [xx]

5.7

What if you are asking our plan to pay you back for our share of the cost
of a drug you have paid for? .................................................................................... [xx]

SECTION 6.
6.1

Taking your appeal to Level 3 and beyond

Levels of Appeal 3, 4, and 5 .................................................................................... [xx]

Making complaints
SECTION 7.

How to make complaints about quality of care, waiting
times, customer service, or other concerns

7.1

What kinds of problems are handled by the complaint process? ...........................[xx]

7.2

The formal name for “making a complaint” is “filing a grievance” ....................... [xx]

7.3

Step-by-step: Making a complaint .......................................................................... [xx]

7.4

You can also make complaints about quality of care to the Quality
Improvement Organization...................................................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 82

Background

SECTION 1

Chapter 7
Section 1.1

Introduction

What to do if you have a problem or
concern

Please call us first
Your health and satisfaction are important to us. When you have a problem or concern, we hope
you’ll try an informal approach first: Please call us at Member Services (phone numbers are on
the cover of this booklet). We will work with you to try to find a satisfactory solution to your
problem.
You have rights as a member of our plan and as someone who is getting Medicare. We pledge to
honor your rights, to take your problems and concerns seriously, and to treat you with respect.
Two formal processes for dealing with problems
Sometimes you might need a formal process for dealing with a problem you are having as a
member of our plan.
This chapter explains two types of formal processes for handling problems:
•

For some types of problems, you need to use the process for coverage decisions and
making appeals.

•

For other types of problems you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt
handling of your problems, each process has a set of rules, procedures, and deadlines that must
be followed by us and by you.
Which one do you use? That depends on the type of problem you are having. The guide in
Section 3 will help you identify the right process to use.

Chapter 7
Section 1.2

What about the legal terms?

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 83

There are technical legal terms for some of the rules, procedures, and types of deadlines
explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to
understand.
To keep things simple, this chapter explains the legal rules and procedures using more common
words in place of certain legal terms. For example, this chapter generally says “making a
complaint” rather than “filing a grievance,” “coverage decision” rather than “coverage
determination,” and “Independent Review Organization” instead of “Independent Review
Entity.” It also uses abbreviations as little as possible.
However, it can be helpful – and sometimes quite important – for you to know the correct legal
terms for the situation you are in. Knowing which terms to use will help you communicate more
clearly and accurately when you are dealing with your problem and get the right help or
information for your situation. To help you know which terms to use, we include legal terms
when we give the details for handling specific types of situations.

SECTION 2

Chapter 7
Section 2.1

You can get help from government
organizations that are not connected with
our plan

Where to get more information and
personalized assistance

Sometimes it can be confusing to start or follow through the process for dealing with a problem.
This can be especially true if you do not feel well or have limited energy. Other times, you may
not have the knowledge you need to take the next step. Perhaps both are true for you.
Get help from an independent government organization
Our plan is always available to help you. But in some situations you may also want help or
guidance from someone who is not part of our plan. You can always contact your State
Health Insurance Assistance Program. This government program has trained counselors in
every state. The program is not connected with our plan or with any insurance company or
health plan. The counselors at this program can help you understand which process you
should use to handle a problem you are having. They can also answer your questions, give
you more information, and offer guidance on what to do. Their services are free. You will find
phone numbers in Chapter 2, Section 3 of this booklet.
You can also get help and information from Medicare

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 84

For more information and help in handling a problem, you can also contact Medicare. Here are
two ways to get information directly from Medicare:
•

You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.

•

You can visit the Medicare website (www.medicare.gov).

SECTION 3

Chapter 7
Section 3.1

To deal with your problem, which process
should you use?

Should you use the process for coverage
decisions and appeals?
Or the process for making complaints?

If you have a problem or concern and you want to do something about it, you don’t need to read
this whole chapter. You just need to find and read the parts of this chapter that apply to your
situation. The guide that follows will help.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 85

Coverage decisions and appeals

SECTION 4

Chapter 7
Section 4.1

A guide to the basics of coverage
decisions and appeals

Asking for coverage decisions and
making appeals: the big picture

The process for coverage decisions and making appeals deals with problems related to your
benefits and coverage for prescription drugs, including problems related to payment. This is the
process you use for issues such as whether a drug is covered or not and the way in which the
drug is covered.
Asking for coverage decisions
A coverage decision is a decision our plan makes about your benefits and coverage or about the
amount we will pay for your covered drugs. You must contact us to ask us for a coverage
decision.
We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay:
•

Usually, there is no problem. We decide the drug is covered and pay our share of the
cost

•

But in some cases we might decide the drug is not covered for you. If you disagree with
this coverage decision, you can make an appeal.

Making an appeal
If our plan makes a coverage decision and you are not satisfied with this decision, you can
“appeal” the decision. An appeal is a formal way of asking our plan to review and change a
coverage decision we have made.
When you make an appeal, our plan reviews the coverage decision we have made to check to see
if our plan was being fair and following all of the rules properly. When we have completed the
review we give you our decision.
If we say no to all or part of your Level 1 appeal, you can go on to a Level 2 appeal. The Level 2
appeal is conducted by an independent organization that is not connected to our plan. If you are

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 86

not satisfied with the decision at the Level 2 appeal, you may be able to continue through several
more levels of appeal.

Chapter 7
Section 4.2

How to get help when you are asking for
a coverage decision or making an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for any
kind of coverage decision or appeal a decision:
•

You can call us at Member Services (phone numbers are on the cover).

•

To get free help from an independent organization that is not connected with our plan,
contact your State Health Insurance Assistance Program (see Section 2 of this chapter).

•

You can, and probably need to, get your doctor or other prescriber involved. In most
situations involving a coverage decision or appeal, your doctor or other prescriber must
explain the medical reasons that support your request. Your doctor or other prescriber
can’t request every appeal. He/she can request a coverage decision and he 1st appeal with
the plan. Your doctor or other prescriber must be appointed as your “representative” to
request any appeal after the 1st appeal level (see below about “representatives”).

•

You can ask someone to act on your behalf. If you want to, you can name another
person to act for you as your “representative” to ask for a coverage decision or make an
appeal.

•

•

There may be someone who is already legally authorized to act as your
representative under State law.

•

If you want a friend, relative, your doctor or other prescriber, or other person to
be your representative, call Member Services and ask for the form to give that
person permission to act on your behalf. The form must be signed by you and by
the person who you would like to act on your behalf. You must give our plan a
copy of the signed form.

You also have the right to hire a lawyer act for you. You may contact your own
lawyer, or get the name of a lawyer from your local bar association or other referral
service. There are also groups that will give you free legal services if you qualify.
However, you are not required to hire a lawyer to ask for any kind of coverage
decision or appeal a decision.

SECTION 5

Your Part D prescription drugs: How to ask
for a coverage decision or make an appeal

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 87

Have you read Section 4 of this chapter (A guide to “the
basics” of coverage decisions and appeals)? If not, you may
want to read it before you start this section.

Chapter 7
Section 5.1

This section tells what to do if you have
problems getting a Part D drug or you
want us to pay you back for a Part D drug

Your benefits as a member of our plan include coverage for many outpatient prescription drugs.
Medicare calls these outpatient prescription drugs “Part D drugs.” You can get these drugs as
long as they are included in our plan’s List of Covered Drugs (Formulary) and they are
medically necessary for you, as determined by your primary care doctor or other prescriber in the
plan’s network.
•

This section is about your Part D drugs only. To keep things simple, we generally say
“drug” in the rest of this section, instead of repeating “covered outpatient prescription
drug” or “Part D drug” every time.

•

For details about what we mean by Part D drugs, the List of Covered Drugs, rules and
restrictions on coverage, and cost information, see Chapter 3 (Using our plan’s coverage
for your Part D prescription drugs) and Chapter 4 (What you pay for your Part D
prescription drugs).

Which of these situations are you in?
Do you want to ask us to make

an exception to the rules or
restrictions on our plan’s
coverage of a drug? (This
includes asking us to cover a
drug that is not on the plan’s
Drug List.)

To ask for an exception
to

rules or restrictions on your
drug coverage, you need to
ask our plan to make a
coverage decision for you.
Go on to the next section of
this chapter (Section 5.2).

Has our plan already told
you that we will not cover
or pay for a drug in the
way that you want it be
covered or paid for?

You can make  an appeal
(this means you are asking
us to reconsider).
Skip ahead to Section 5.5
of this chapter. (You may
also want to read Sections
5.2 and 5.3, which explain
important things to know
about asking for exceptions
to the plan’s coverage for
your prescription drugs.)

Do you want to

ask our plan to
pay you back for
a drug you have
already received
and paid for?

You can  send us
the bill. Skip
ahead to Section
5.6 of this
chapter.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 88

Chapter 7
Section 5.2

What kinds of exceptions to the
coverage rules can you ask for?

If a drug is not covered in the way you would like it to be covered, you can ask the plan to make
an “exception” to our coverage rules. An exception is a type of coverage decision. Like for other
types of coverage decisions, if we turn down your request for an exception, you can appeal our
decision.
When you ask for an exception to our Part D drug coverage rules, your doctor or other prescriber
will need to explain the medical reasons. We will then consider your request. You or your doctor
or other prescriber can ask us to make any of these four types of exceptions:
1. Make an exception to the rules and cover a drug for you that is not on our plan’s
List of Covered Drugs (Formulary). (We call it the “Drug List” for short.)
Asking for coverage of a drug that is not on the Drug
List is sometimes called asking for a “formulary
exception.”
•

If we agree to make an exception and cover a drug that is not on the Drug List, you will
need to pay the cost-sharing amount that applies to [insert as appropriate: all of our
drugs OR drugs in [insert exceptions cost group]]. You cannot ask for an exception to the
copayment or coinsurance amount we require you to pay for the drug.

•

You cannot ask for coverage of any “excluded drugs” which are drugs that Medicare does
not cover. (For more about excluded drugs, see Chapter 3.)

2. Make an exception to the rules and cover a brand-name drug for you instead of the
generic version.
Asking for coverage of a brand-name drug when a
generic is available is sometimes called asking for a
“formulary exception.”
•

Generally, we require the network pharmacies to fill your prescription for a brand-name
drug with a generic drug, if a generic is available.

•

If your doctor or other prescriber thinks you need the brand-name version and we agree
to cover it, you must pay the brand copayment for the brand drug.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 89

3. Make an exception to the rules by removing a restriction on the plan’s coverage for a
covered drug. There are extra rules or restrictions that apply to certain drugs on the plan’s
List of Covered Drugs (for more information, go to Chapter 3 and look for Section 5).
Asking for removal of a restriction on coverage for a
drug is sometimes called asking for a “formulary
exception.”
The extra rules and restrictions on coverage for certain drugs include:
•

[Omit if plan does not use prior authorization] Getting plan approval in advance before
we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)

•

[Omit if plan does not use step therapy] Being required to try a different drug first before
we will agree to cover the drug you are asking for. (This is sometimes called “step
therapy.”)]

•

[Omit if plan does not use quantity limits] Quantity limits. For some drugs, there are
restrictions on the amount of the drug you can have.

•

If our plan agrees to make an exception and waive a coverage restriction on a covered
drug for you, you can ask for a change to the Cost Group for that drug.

4. [Plans without drug cost groups should omit this section] Make an exception to the rules
by changing coverage of a drug to a lower Cost Group. Every drug on the plan’s Drug
List is in one of [insert number of cost groups] Cost Groups. In general, the lower the Cost
Group number, the less you will pay as your share of the cost of the drug.
Since Cost Groups are sometimes called “tiers,” asking
for a change to the Cost Group is sometimes called
asking for a “tiering exception.”
•

If your drug is in [insert name of non-preferred/highest cost group subject to the tiering
exceptions process] you can ask us to cover it at the cost-sharing amount that applies to
drugs in [insert name of preferred/lowest cost group subject to the tiering exceptions
process]. This would lower your share of the cost for the drug.

•

[If the Plan designated one of its cost groups as a “high-cost/unique drug cost group”
and is exempting that cost group from the exceptions process, include the following
language: You cannot ask us to change the Cost Group for any drug in [insert cost group
number and name of cost group designated as the high-cost/unique drug cost group].]

•

If our plan agrees to make an exception and cover a drug for you that is not on our Drug
List, you can ask for a change to the Cost Group for that drug.

•

If our plan agrees to make an exception and waive a coverage restriction on a covered
drug for you, you can ask for a change to the Cost Group for that drug.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 90

Chapter 7
Section 5.3

Important things to know about asking
for exceptions to the rules for coverage
of Part D drugs

Who can ask for an exception?
You, your doctor or other prescriber, or someone else who is acting on your behalf can ask
for an exception to our rules for coverage of your Part D drugs. (Section 4 of this chapter tells
how you can give written permission to someone else to act as your representative. You can also
have a lawyer act on your behalf.)
Your doctor or other prescriber must tell us the medical reasons
Your doctor or other prescriber must give us a written statement that explains the medical
reasons for requesting an exception. For a faster decision, include this medical information from
the doctor or other prescriber when you ask for the exception.
Typically, our Drug List includes more than one drug for treating a particular condition. These
different possibilities are called “alternative” drugs. If an alternative drug would be just as
effective as the drug you are requesting and would not cause more side effects or other health
problems, we will generally not approve your request for an exception.
Our plan can say yes or no to your request
•

If we approve your request for an exception, our approval usually is valid until the end of
the plan year. This is true as long as your doctor continues to prescribe the drug for you
and that drug continues to be safe and effective for treating your condition.

•

If we say no to your request for an exception, you can ask for a review of our decision by
making an appeal. Section 5.4 tells how to make an appeal if we say no.

Ask for help if you need it
•

If you have questions or need help at any time, please call Member Services (phone
numbers are on the front cover of this booklet). Or call your State Health Insurance
Assistance Program, a government organization that provides personalized assistance
(see Section 2 of this chapter).

Chapter 7
Section 5.4

Step-by-step: How to ask for an exception
(how to ask our plan to make an exception
for you)

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 91

An exception is a type of coverage
decision. A coverage decision is called an
“initial determination” or “initial
decision.” When the coverage decision is
about your Part D drugs, the initial
determination is called a “coverage
determination.”
Step 1

You ask our plan to make an exception to the plan’s rules
for drug coverage. When you ask us to make this exception,
you are asking us to make a coverage decision about your
drugs. If your health requires a quick response, you must ask
us to make a “fast decision.”

What to do
•

Request the exception you want. Start by [insert if applicable: calling,] writing,
or faxing our plan to make your request for an exception. You, your doctor or other
prescriber, or your representative can do this (see Section 5.2 above). For the
details, including how to reach us on evenings and weekends, go to Chapter 2,
Section 1 and look for the section called, [plans may edit section title as
necessary:] How to reach our plan when you are asking for a coverage decision
about your Part D prescription drugs.

•

Provide the “doctor’s statement.” Your doctor or other prescriber must give us
the medical reasons for the drug exception you are requesting. (We call this the
“doctor’s statement.”) Your doctor or other prescriber can fax or mail the
statement to our plan. Or your doctor or other prescriber can tell us on the phone
and follow up by faxing or mailing the signed statement.

If your health requires it, ask us to give you a “fast decision”
A “fast decision” is called an
“expedited decision.”
•

When we give you our decision, we will use the “standard” deadlines unless we
have agreed to use the “fast” deadlines. A standard decision means we will give
you an answer within 72 hours after we receive your doctor or other prescriber’s
statement. A fast decision means we will answer within 24 hours.

•

To get a fast decision, you must meet two requirements:
o You can get a fast decision only if you are asking for an exception for a drug
you have not yet received. (You cannot get a fast decision if your request is
about a drug you are already taking.)

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 92

o You can get a fast decision only if using the standard deadlines could cause
serious harm to your health or hurt your ability to function.
•

If your doctor or other prescriber tells us that your health requires a “fast
decision,” we will automatically agree to give you a fast decision.

•

If you ask for a fast decision on your own, without your doctor or your other
prescriber’s support, our plan will decide whether your health requires that we give
you a fast decision.
o If we decide that your medical condition does not meet the requirements for a
fast decision, we will send you a letter that says so (and we will use the
standard deadlines instead).
o This letter will tell you that if your doctor or other prescriber asks for the fast
decision, we will automatically give a fast decision.
o The letter will also tell how you can file a complaint about our decision to give
you a standard decision instead of the fast decision you requested. It tells how
to file a “fast” complaint, which means you would get our answer to your
complaint within 24 hours. (The process for making a complaint is different
from the process for coverage decisions and appeals. For more about the
process for making complaints, see Section 7 of this chapter.)

Step 2

•

Our plan considers your request for a drug
coverage exception and we give you our answer.

If we are using the fast deadlines, we must give you our answer within 24
hours.
o Generally, this means within 24 hours after we receive your doctor or other
prescriber’s statement supporting your request. We will give you our answer
sooner if your health requires us to.
o (If we do not meet this deadline, we are required to send your request on to
Level 2 of the appeals process, where it will be reviewed by an independent
outside organization. Later in this section, we tell about this review organization
and explain what happens at Appeal Level 2 of the appeals process.)

•

If our answer is yes to part or all of what you requested, we must provide the
coverage exception we have agreed to provide within 24 hours. Generally, this means
within 24 hours after we receive your doctor or other prescriber’s statement
supporting your request.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 93

•

If we are using the standard deadlines, we must give you our answer within 72
hours.

•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 72 hours. Generally, this means within 72
hours after we receive your doctor or other prescriber’s statement supporting your
request.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.

Step 3

•

If we say no to your request for a drug coverage
exception, you decide if you want to make an
appeal

If our plan says no, you have the right to make an appeal. Making an appeal means
making another try to get the exception you want. It means asking us to reconsider –
and possibly change – the decision we made.

Chapter 7
Section 5.5

Step-by-step: How to make a
Level 1 Appeal
(how to ask for a review of a coverage
decision made by our plan)
When you start the appeals process by
making an appeal, it is called the “first level
of appeal” or a “Level 1 Appeal.”
An appeal to the plan about a Part D drug
coverage decision is called a plan
“redetermination.”

Step 1

What to do

You contact our plan and make your level 1 appeal.
If your health requires a quick response,
you must ask for a “fast appeal.”

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 94

•

To start your appeal, you (or your doctor or your representative) must
contact our plan.
o For details on how to reach us by phone, fax, mail, or in person for any
purpose related to your appeal, go to Chapter 2, Section 1, and look for the
section called, [plans may edit section title as necessary:] How to reach
our plan when you are making an appeal about your Part D prescription
drugs.

•

Make your appeal in writing by signing and submitting a request. The plan
may create a request form or you can send a letter. [If the plan accepts oral
requests for standard appeals, insert: You may also ask for an appeal by calling us
at the phone number shown in Chapter 2, Section 1 [plans may edit section title as
necessary:] (How to reach our plan when you are making an appeal about your
Part D prescription drugs).]

•

You must make your appeal request within 60 calendar days from the date on
the written notice we sent to tell you our answer to your request for a coverage
decision. If you miss this deadline and have a good reason for missing it, we may
give you more time to make your appeal.

•

You can ask for a copy of the information in your appeal and add more
information.
o You have the right to ask us for a copy of the information regarding your
appeal. [If a fee is charged, insert: We are allowed to charge a fee for
copying and sending this information to you.]
o If you wish, you and your doctor or other prescriber may give us additional
information to support your appeal.

If your health requires it, ask for a “fast appeal”
A “fast appeal” is also called an “expedited
appeal.”
•

If you are appealing a decision our plan made about a drug you have not yet received,
you and your doctor will need to decide if you need a “fast appeal.”

•

The requirements and procedures for getting a “fast appeal” are the same as those
for getting a “fast decision”. To ask for a fast appeal, follow the instructions for
asking for a fast decision that are given in Section 5.4 of this chapter.

•

[If there are different phone numbers/fax numbers/addresses for expedited
appeals requests, need to provide.]

Step 2

Our plan considers your appeal
and we give you our answer.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 95

•

When our plan is reviewing your appeal, we take another careful look at all of the
information about your request for an exception to the drug coverage rules. We check
to see if we were being fair and following all the rules when we said no to your request.
We may contact you or your doctor to get more information.

•

If we are using the fast deadlines, we must give you our answer within 72 hours
after we receive your appeal. We will give you our answer sooner if your health
requires it.
o If we do not give you an answer within 72 hours, we are required to send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent outside organization. Later in this section, we tell about this review
organization and explain what happens at Appeal Level 2 of the appeals
process.)

•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 72 hours.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.

•

If we are using the standard deadlines, we must give you our answer within 7
calendar days after we receive your appeal. We will give you our decision sooner if
you have not received the drug yet and your health condition requires us to do so.
o If we do not give you a decision within 7 calendar days, we are required to send
your request on to Level 2 of the appeals process, where it will be reviewed by
an independent outside organization. Later in this section, we tell about this
review organization and explain what happens at Appeal Level 2 of the appeals
process.

•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide as quickly as your health requires, but no later
than 7 calendar days after we receive your appeal.

•

If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.

Step 3

If we say no to your appeal, you decide if
you want to continue with the appeals
process and make another appeal.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 96

•

If our plan says no to your appeal, you then choose whether to accept this decision or
continue by making another appeal.

•

If you decide to make another appeal, it means your appeal is going on to Level 2 of
the appeals process (see below).

Chapter 7
Section 5.6

Step-by-step: How to make a
Level 2 Appeal

If our plan says no to your appeal, you then choose whether to accept this decision or continue
by making another appeal. If you decide to go on to a Level 2 appeal, the Independent Review
Organization reviews the decision our plan made when we said no to your first appeal. This
organization decides whether the decision we made should be changed.
The formal name for the “Independent
Review Organization” is the “Independent
Review Entity.” It is sometimes called the
“IRE.”
Step 1

To make a Level 2 Appeal, you must contact the
Independent Review Organization and ask for a
review of your case.

•

If our plan says no to your Level 1 appeal, the written notice we send you will include
instructions on how to make a Level 2 appeal with the Independent Review
Organization. These instructions will tell who can make this Level 2 appeal, what
deadlines you must follow, and how to reach the review organization.

•

When you make an appeal to the Independent Review Organization, we will send the
information about your appeal to this organization. This information is called your “case
file.” You have the right to ask us for a copy of your case file. [If a fee is charged,
insert: We are allowed to charge you a fee for copying and sending this information to
you.]
Step 2

•

The Independent Review Organization does a
review of your appeal and gives you an answer.

The Independent Review Organization is an outside, independent organization that
is hired by Medicare. This organization is not connected with our plan and it is not a
government agency. This organization is a company chosen by Medicare to handle the
job of being the Independent Review Organization. Medicare oversees its work.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 97

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal. The organization will tell you its decision in writing
and explain the reasons for it.

•

If your health requires it, ask the Independent Review Organization for a “fast appeal.”

•

If the review organization agrees to give you a “fast appeal,” the review organization
must give you an answer to your Level 2 appeal within 72 hours of when it receives
your appeal.

•

If the Independent Review Organization says yes to part or all of what you
requested, we must provide the drug coverage that was approved by the review
organization within 24 hours after we receive the decision from the review organization.

•

If you have a standard appeal at Level 2, the review organization must give you an
answer to your Level 2 appeal within 7 calendar days of when it receives your appeal.

•

If the Independent Review Organization says yes to part or all of what you
requested, we must provide the drug coverage that was approved by the review
organization within 72 hours after we receive the decision from the review organization.

Step 3

•

If your case meets the requirements, you
choose whether you want to take your appeal
further

If your Level 2 appeal is turned down and you meet the requirements to continue with the
appeals process, you must decide whether you want to go on to Level 3 and make a third
appeal. If you decide to make a third appeal, the details on how to do this are in the
written notice you got after your second appeal.
o If the Independent Review Organization says no to your appeals, it means they
agree with our plan that your request should not be approved. (This is called
“upholding the decision.” It is also called “turning down your appeal.”)
o The notice you get from the Independent Review Organization will tell you in
writing if your case meets the requirements for continuing with the appeals
process. For example, to continue and make another appeal at Level 3, the dollar
value of the drug coverage you are requesting must meet a certain minimum. If
the dollar value of the coverage you are requesting is too low, you cannot make
another appeal, which means that the decision at Level 2 is final.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 98

•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal).

•

Appeal Level 3 is handled by an administrative judge. Section 6 in this chapter tells more
about Levels 3, 4, and 5 of the appeals process.

Chapter 7
Section 5.7

What if you are asking our plan to pay you
back for our share of the cost of a drug
you have paid for?

If you want to ask our plan to pay you back for a drug, start by reading Chapter 5 of this booklet:
Asking the plan to pay its share of the cost of a drug. Chapter 5 describes the situations in which
you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to
pay you back for our share of the cost of a drug you have paid for.
Asking for reimbursement is asking for a coverage decision from our plan
If you send us the paperwork that asks for reimbursement, you are usually asking us to make a
coverage decision (for more about coverage decisions, see Section 4.2 of this chapter). Some
examples of asking for reimbursement that would be considered coverage decisions are when
you use an out-of-network pharmacy to get a prescription filled, when you pay the full cost for a
prescription because you don’t have your plan membership card with you, and when you pay the
full cost for a prescription in other situations. To make this coverage decision, we will check to
see if the drug you paid for is a covered drug. We will also check to see if you followed all the
rules for using your coverage for drugs (these rules are given in Chapter 6 of this booklet).
We will say yes or no to your request
•

If the drug is covered and you followed all the rules, we will send you the payment for our
share of the cost of your drug. (When we send the payment, it’s the same as saying yes to
your request for a coverage decision.)
o [Plans with no deductible or coverage gap, omit this bullet.] NOTE: It is possible
that you followed all the rules but you are in [insert as applicable: the Deductible
Stage OR the Coverage Gap Stage OR either the Deductible Stage or the Coverage
Gap Stage.] In [insert as applicable: this period OR either of those periods], you pay
the full cost of your drugs until you qualify for the next period. If you have followed
all the rules, we will count your payment towards your out-of-pocket total even
though we cannot reimburse you. (For more information about the [insert as
applicable: Deductible Stage OR Coverage Gap Stage OR Deductible Stage and
Coverage Gap Stage], see Chapter 4.)

•

If the drug is not covered, or you did not follow all the rules, we will not reimburse you.
Instead, we will send you a letter that says we will not reimburse you and explains why.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 99

(When we turn down your request for reimbursement, it’s the same as saying no to your
request for a coverage decision.)
What if you ask us to reimburse you and we say that we will not?
If you think we have made a mistake in turning you down, you can make an appeal. If you
make an appeal, it means you are asking us to change the coverage decision we made when
we turned down your request for reimbursement.
To make this appeal, follow the process for appeals that we describe in section 5.5 of this
chapter. See Section 5.5 in this chapter for step-by-step instructions. When you are following
these instructions, please note:
•

If you make an appeal for reimbursement, the standard deadlines apply to all parts of
the appeals process. (If you are requesting payment for a drug you have already received,
you are not allowed to ask for a fast appeal.)

•

At any stage of the appeals process, if the answer to your appeal is yes, then our plan must
provide the reimbursement you have requested. We are required to send payment to you
within 30 days.
o The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It will
give you the details about how to go on to Appeal Level 3, which is handled by a
judge.
Step 3

If the Independent Review Organization turns
down your appeal, you choose whether you want
to take your appeal further

•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to
accept their decision or go on to Level 3 and make a third appeal.

•

Section 7 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 7

Chapter 7
Section 6.1

Taking your appeal to Level 3 and
beyond

Levels of Appeal 3, 4, and 5

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)100

This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal,
and both of your appeals have been turned down.
If the dollar value of the drug or medical service you have appealed meets certain minimum
levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the
minimum level, you cannot appeal any further. If the dollar value is high enough, the written
response you receive to your Level 2 appeal will explain who to contact and what to do to ask for
a Level 3 appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
A judge who works for the Federal government will
review your appeal and give you an answer. This judge is
called an “Administrative Law Judge.”
•

If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved.

•

If the answer is no, the appeals process may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you can continue to the next level of the
review process. If the administrative judge says no to your appeal, the notice you
get will tell you what to do next if you choose to continue with you appeal.
Whenever the reviewer says no to your appeal, the notice you get will tell you
whether the rules allow you to go on to another level of appeal. If the rules allow
you to go on, the written notice will also tell you who to contact and what to do next
if you choose to continue with your appeal.
The Medicare Appeals Council will review your appeal
and give you an answer. The Medicare Appeals Council
works for the Federal government.

•

If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved.

•

If the answer is no, the appeals process may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you might be able to continue to the next
level of the review process. It depends on your situation. Whenever the reviewer
says no to your appeal, the notice you get will tell you whether the rules allow you

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)101

to go on to another level of appeal. If the rules allow you to go on, the written
notice will also tell you who to contact and what to do next if you choose to
continue with your appeal.
A judge at the Federal District Court will review
your appeal. This is the last stage of the appeals
process.
•

The Level 5 Appeal decision is the final decision in the administrative appeals process.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)102

Making complaints

How to make a complaint about
quality of care, waiting times,
customer service, or other concerns

SECTION 7

If your problem is about decisions related to benefits,
coverage, or payment, then this section is not for you.
Instead, you need to use the process for coverage decisions
and appeals. Go to Section 4 of this chapter.

Chapter 7
Section 7.1

What kinds of problems are handled by
the complaint process?

This section explains how to use the process for making complaints. The complaint process is
used for certain types of problems only. This includes problems related to quality of care, waiting
times, and the customer service you receive. Here are examples of the kinds of problems handled
by the complaint process.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)103

Some possible
reasons for
complaints

If you have any of
these kinds of
problems, you can
“make a complaint”

Quality of your care

Waiting times

Are you unhappy with the quality of the
care you’ve received?

Have you been kept waiting too long:
•

Respecting your privacy
Do you believe that someone did not
respect your right to privacy or shared
information about you that you feel should
be confidential?

Disrespect, poor customer service,
or other negative behaviors
•

Has someone been rude or
disrespectful to you?

•

Are you unhappy with how our plan’s
Member Services has dealt with you?

•

Do you feel you are being encouraged
to leave our plan (disenroll from our
plan)?

By pharmacists?

• By Member Services or other staff at
our plan?
Examples include waiting too long on the
phone or when getting a prescription.

Information you get from our plan
•

Do you believe we haven’t given you
a notice that we’re required to give?

•

Do you think written information we
have given you is hard to understand?

Cleanliness
•

Are you unhappy with the cleanliness
or condition of a pharmacy?

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)104

Possible reasons,
continued

These types of complaints
are all related to the

timeliness of our actions
related to coverage
decisions and appeals

The process of asking for a coverage decision and making appeals is explained
in sections 4 and 5 of this chapter. If you are asking for a decision or making
an appeal, you use that process, not the complaint process.
However, if you have already asked for a coverage decision or made an appeal,
and you think that our plan is not responding quickly enough, you can also
make a complaint about our slowness. Here are examples:
•

If you have asked our plan to give
you a “fast response” for a coverage
decision or appeal, and we have said
we will not, you can make a
complaint.

•

If you believe our plan is not
meeting the deadlines for giving you
a coverage decision or an answer to
an appeal you have made, you can
make a complaint.

•

When a coverage decision we made
is reviewed and our plan is told that
we must cover or reimburse you for
certain drugs, there are deadlines
that apply. If you think we are not
meeting these deadlines, you can
make a complaint.

•

When our plan does not give you a
decision on time, we are required to
forward your case to the
Independent Review Organization.
If we don’t do that within the
required deadline, you can make a
complaint.

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)105

Chapter 7
Section 7.2

Chapter 7
Section 7.3

Step 1

The formal name for “making a
complaint” is “filing a grievance”

•

What this section calls a “complaint” is also called
a “grievance.”

•

Another term for “making a complaint” is “filing
a grievance.”

•

Another way to say “using the process for
complaints” is “using the process for filing a
grievance.”

Step-by-step: Making a complaint

Contact us promptly – either by phone
or in writing

•

Usually, calling Member Services is the first step. If there is anything else you need to
do, Member Services will let you know. [Insert phone number, TTY/TDD, and hours of
operation.]

•

If you do not wish to call (or you called and were not satisfied), you can put your
complaint in writing and send it to us. If you do this, it means that we will use our formal
procedure for answering grievances. Here’s how it works:
o [Insert description of the procedures (including time frames) and instructions
about what members need to do if they want to use the formal process for making
a complaint. Describe expedited grievance time frames for grievances about
decisions to not conduct expedited organization/coverage determinations or
reconsiderations/redeterminations.]

•

Whether you call or write, you should contact Member Services right away. The
complaint must be made within 60 days after you had the problem you want to complain
about.

•

In some cases, you may ask for a “fast” complaint. You may ask for “fast” complaint if
the plan denies your request for a “fast” coverage decision or a “fast” Level 1 appeal. If you
ask for a “fast” complaint, and we agree to give it to you, we will give you an answer
within 24 hours. You can ask for a “fast” complaint if you think a slower response could

2010 Evidence of Coverage for [insert plan name]
Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)106

harm your health or hurt your ability to function. Requests for “fast” complaints can be
done over the phone or in writing.
What this section calls a “fast complaint” is
also called a “fast grievance.”

Step 2

We look into your complaint and
give you our answer

•

If possible, we will answer you right away. If you call us with a complaint, we may be
able to give you an answer on the same phone call. If your health condition requires us to
answer quickly, we will do that.

•

Most complaints are answered in 30 days, but we may take up to 44 days. If we need
more information and the delay is in your best interest or if you ask for more time, we can
take up to 14 more days (44 days total) to answer your complaint.

•

If we do not agree with some or all of your complaint or don’t take responsibility for the
problem you are complaining about, we will let you know by phone or in writing. Our
response will include our reasons for this answer. We must respond whether we agree with
the complaint or not.

Chapter 7
Section 7.4

You can also make complaints about
quality of care to the Quality Improvement
Organization

You can make your complaint about the quality of care you received to our plan by using the
step-by-step process outlined above.
When your complaint is about quality of care, you also have two extra options:
•

You can make your complaint to the Quality Improvement Organization. If you
prefer, you can make your complaint about the quality of care you received directly to
this organization (without making the complaint to our plan). To find the name,
address, and phone number of the Quality Improvement Organization in your state,
look in Chapter 2, Section 4, of this booklet. If you make a complaint to this
organization, we will work together with them to resolve your complaint.

•

Or you can make your complaint to both at the same time. If you wish, you can make
your complaint about quality of care to our plan and also to the Quality Improvement
Organization.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

109

CHAPTER 8: Ending your membership in the plan

SECTION 1. Introduction
1.1 This chapter focuses on ending your membership in our plan ................................. [xx]

SECTION 2. When can you end your membership in our plan?
2.1

You can end your membership during the Annual Enrollment Period ................... [xx]

2.2

You can end your membership during the Medicare Advantage Open
Enrollment Period, but your plan choices are more limited .................................... [xx]

2.3

In certain situations, you can end your membership during a Special
Enrollment Period ...................................................................................................[xx]

2.4

Where can you get more information about when you can end your
membership? ........................................................................................................... [xx]

SECTION 3. How do you end your membership in our plan?
3.1

Usually, you end your membership by enrolling in another plan ............................. [xx]

SECTION 4. Until your membership ends, you must keep getting your
drugs through our plan
4.1 Until your membership ends, you are still a member of our plan............................. [xx]

SECTION 5. In certain situations, [insert plan name] can end your
membership in the plan
5.1 When will we end your membership in the plan?..................................................... [xx]
5.2 We cannot ask you to leave for any reason related to your health ........................... [xx]
5.3 What can you do if we end your membership?......................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

SECTION 1

Chapter 8
Section 1.1

110

Introduction

This chapter focuses on ending your
membership in our plan

Ending your membership in [insert plan name] may be voluntary (your own choice) or
involuntary (not your own choice):
•

You might leave our plan because you have decided that you want to leave.
o There are only certain times during the year, or certain situations, when you may
end your membership in the plan. Section 2 tells you when you can end your
membership in the plan.
o The process for ending your membership varies depending on what type of new
coverage you are choosing. Section 3 tells you how to end your membership in
each situation.

•

There are also limited situations where we are required to end your membership. Section
5 tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your Part D prescription drugs through our
plan until your membership ends.

SECTION 2

When can you end your membership in
our plan?

You may end your membership in our plan only during certain times of the year, known as
enrollment periods. All members have the opportunity to leave the plan during the Annual
Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times
of the year.
Chapter 8
Section 2.1

You can end your membership during the
Annual Enrollment Period

You can end your membership during the Annual Enrollment Period (also known as the
“Annual Coordinated Election Period”). This is the time when you should review your health
and drug coverage and make a decision about your coverage for the upcoming year.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

111

•

When is the Annual Enrollment Period? This happens every year from November
15 to December 31.

•

What type of plan can you switch to during the Annual Enrollment Period?
During this time, you can review your health coverage and your prescription drug
coverage. You can choose to keep your current coverage or make changes to your
coverage for the upcoming year. If you decide to change to a new plan, you can
choose any of the following types of plans:
o Another Medicare prescription drug plan
o The Original Medicare without a separate Medicare prescription drug plan.
o – or – A Medicare Advantage plan. A Medicare Advantage plan is a plan
offered by a private company that contracts with Medicare to provide all of
the Medicare Part A (Hospital) and Part B (Medical) benefits. Some Medicare
Advantage plans also include Part D prescription drug coverage.
•

If you enroll in most Medicare Advantage plans, you will be
disenrolled from [insert plan name] when your new plan’s coverage
begins. However, if you choose a Private Fee-For-Service plan without
Part D drug coverage, a Medicare Medical Savings Account plan, or a
Medicare Cost Plan, you can enroll in that plan and keep [insert plan
name] for your drug coverage. If you do not want to keep our plan,
you can choose to enroll in another Medicare prescription drug plan or
to drop Medicare prescription drug coverage.

Note: If you disenroll from a Medicare prescription drug plan and go without
creditable prescription drug coverage, you may need to pay a late enrollment
penalty if you join a Medicare drug plan later. (“Creditable” coverage means
the coverage is at least as good as Medicare’s standard prescription drug
coverage.)
•

When will your membership end? Your membership will end when your new
plan’s coverage begins on January 1.

Chapter 10
Section 2.2

You can end your membership during the
Medicare Advantage Open Enrollment
Period, but your plan choices are more
limited

You have the opportunity to make one change to your health coverage during the Medicare
Advantage Open Enrollment Period.
•

When is the Medicare Advantage Open Enrollment Period? This happens every
year from January 1 to March 31.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

•

112

What type of plan can you switch to during the Medicare Advantage Open
Enrollment Period? During this time, you can make one change to your health plan
coverage. However, you may not add or drop prescription drug coverage during this
time. Since you are currently enrolled in a Medicare prescription drug plan, this
means that you can enroll in:
o A Medicare Advantage plan with prescription drug coverage. (A Medicare
Advantage plan is a plan offered by a private company that contracts with
Medicare to provide all of the Medicare Part A (Hospital) and Part B
(Medical) benefits.)
o Note: You can also enroll in a Medicare Private Fee-For-Service Plan without
prescription drug coverage or a Medicare Cost Plan. But in these cases, you
must keep your prescription drug coverage through our plan.

•

When will your membership end? Your membership will end on the first day of the
month after we get your request to change plans.

Chapter 8
Section 2.3

In certain situations, you can end your
membership during a Special Enrollment
Period

In certain situations, members of [insert plan name] may be eligible to end their membership at
other times of the year. This is known as a Special Enrollment Period.
•

Who is eligible for a Special Enrollment Period? If any of the following situations
apply to you, you are eligible to end your membership during a Special Enrollment
Period. These are just examples, for the full list you can contact the plan, call 1-800MEDICARE, or visit the Medicare website at www.Medicare.gov:
o If you have moved.
o If you have Medicaid.
o If you are eligible for Extra Help with paying for your Medicare prescriptions.
o If you live in a facility, such as a nursing home.

•

When are Special Enrollment Periods? The enrollment periods vary depending on
your situation.

•

What can you do? If you are eligible to end your membership because of a special
situation, you can choose to change both your Medicare health coverage and
prescription drug coverage. This means you can choose any of the following types of
plans:
o Another Medicare prescription drug plan

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

113

o Original Medicare without a separate Medicare prescription drug plan
o – or – A Medicare Advantage plan. A Medicare Advantage plan is a plan
offered by a private company that contracts with Medicare to provide all of
the Medicare Part A (Hospital) and Part B (Medical) benefits. Some Medicare
Advantage plans also include Part D prescription drug coverage.
•

If you enroll in most Medicare Advantage plans, you will
automatically be disenrolled from [insert plan name] when your new
plan’s coverage begins. However, if you choose a Private Fee-ForService plan without Part D drug coverage, a Medicare Medical
Savings Account plan, or a Medicare Cost Plan, you can enroll in that
plan and keep [insert plan name] for your drug coverage. If you do not
want to keep our plan, you can choose to enroll in another Medicare
prescription drug plan or to drop Medicare prescription drug coverage.

Note: If you disenroll from a Medicare prescription drug plan and go without
creditable prescription drug coverage, you may need to pay a late enrollment
penalty if you join a Medicare drug plan later. (“Creditable” coverage means
the coverage is at least as good as Medicare’s standard prescription drug
coverage.)
•

When will your membership end? Your membership will usually end on the first
day of the month after we receive your request to change your plan.

Chapter 8
Section 2.4

Where can you get more information
about when you can end your
membership?

If you have any questions or would like more information on when you can end your
membership:
•

You can call Member Services (phone numbers are on the cover of this booklet).

•

You can find the information in the Medicare & You 2010 handbook.
o Everyone with Medicare receives a copy of Medicare & You each fall. Those
new to Medicare receive it within a month after first signing up.
o You can also download a copy from www.medicare.gov. Or, you can order a
printed copy by calling Medicare at the number below.

•

You can contact Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7
days a week. TTY users should call 1-877-486-2048.

SECTION 3

How do you end your membership in

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

114

our plan?

Chapter 8
Section 3.1

You end your membership by enrolling in
another plan

Usually, to end your membership in our plan, you simply enroll in another Medicare plan during
one of the enrollment periods (see Section 2 for information about the enrollment periods). There
are a couple of exceptions:
•

One exception is when you want to switch from our plan to Original Medicare
without a Medicare prescription drug plan. In this situation, you must contact [insert
plan name] Member Services and ask to be disenrolled from our plan.

• Another exception is if you join a Private Fee-For-Service plan without prescription
drug coverage, a Medicare Medical Savings Account Plan, or a Medicare Cost Plan.
In this case, you can enroll in that plan and keep [insert plan name] for your drug
coverage. If you do not want to keep our plan, you can choose to enroll in another
Medicare prescription drug plan or to drop your Medicare prescription drug coverage
The table below explains how you should end your membership in our plan.

If you would like to switch
from our plan to:
•

Another Medicare
prescription drug plan

This is what you should do:

•

Enroll in the new Medicare prescription
drug plan.
You will automatically be disenrolled
from [insert plan name] when your new
plan’s coverage begins.

•

A Medicare Advantage plan

•

Enroll in the Medicare Advantage plan.
With most Medicare Advantage plans,
you will automatically be disenrolled
from [insert plan name] when your new
plan’s coverage begins.
However, if you choose a Private FeeFor-Service plan without Part D drug

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

If you would like to switch
from our plan to:

115

This is what you should do:

coverage, a Medicare Medical Savings
Account plan, or a Medicare Cost Plan,
you can enroll in that new plan and keep
[insert plan name] for your drug
coverage. If you want to leave our plan,
you must either enroll in another
Medicare prescription drug plan or
contact Member Services or Medicare
and ask to be disenrolled.
•

Original Medicare without a
separate Medicare
prescription drug plan

SECTION 4

Chapter 8
Section 4.1

•

Contact Member Services and ask to
be disenrolled from the plan (phone
numbers are on the cover of this
booklet).

•

You can also contact Medicare at 1800-MEDICARE (1-800-633-4227) and
ask to be disenrolled. TTY users should
call 1-877-486-2048.

Until your membership ends, you
must keep getting your drugs through
our plan

Until your membership ends, you are still
a member of our plan

If you leave [insert plan name], it may take time before your membership ends and your new
Medicare coverage goes into effect. (See Section 2 for information on when your new coverage
begins.) During this time, you must continue to get your prescription drugs through our plan.
•

You should continue to use our network pharmacies to get your prescriptions filled
until your membership in our plan ends. Usually, your prescription drugs are only

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

116

covered if they are filled at a network pharmacy [insert if applicable: including through
our mail-order pharmacy services.]

SECTION 5

Chapter 8
Section 5.1

[Insert plan name] can end your
membership in the plan

When will we end your membership in the
plan?

[Insert plan name] must end your membership in the plan if any of the following happen:
•

If you do not stay continuously enrolled in Medicare Part A or Part B (or both).

•

If you move out of our service area for more than six months.
o If you move or take a long trip, you need to call Member Services to find out if
the place you are moving or traveling to is in our plan’s area.

•

If you lie about or withhold information about other insurance you have that provides
prescription drug coverage.

•

[Omit if not applicable] If you intentionally give us incorrect information when you are
enrolling in our plan and that information affects your eligibility for our plan.]

•

[Omit bullet and sub-bullet if not applicable] If you continuously behave in a way that is
disruptive and makes it difficult for us to provide care for you and other members of our
plan.
o We cannot make you leave our plan for this reason unless we get permission from
Medicare first.

•

[Omit bullet and sub-bullet if not applicable] If you let someone else use your
membership card to get prescription drugs.
o If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.

•

[Omit bullet and sub-bullet if not applicable] If you do not pay the plan premiums for
[insert length of grace period].
o We must notify you in writing that you have [insert length of grace period] to pay
the plan premium before we end your membership.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Ending your membership in the plan

117

Where can you get more information?
If you have questions or would like more information on when we can end your membership:
•

You can call Member Services for more information (phone numbers are on the cover of
this booklet).

Chapter 8
Section 5.2

We cannot ask you to leave our plan for
any reason related to your health

What should you do if this happens?
If you feel that you are being asked to leave our plan because of a health-related reason, you
should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877486-2048. You may call 24 hours a day, 7 days a week.

Chapter 8
Section 5.3

You have the right to make a complaint
if we end your membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your
membership. We must also explain how you can make a complaint about our decision to end
your membership. You can also look in Chapter 7, Section 7 for information about how to make
a complaint.

2010 Evidence of Coverage for [insert plan name]
Chapter 9: Legal notices

118

CHAPTER 9: Legal notices
SECTION 1. Notice about governing law.................................................................. [xx]
SECTION 2. Notice about nondiscrimination ............................................................ [xx]

[Note: You may include other legal notices, such as a notice of member non-liability or a notice
about third-party liability. These notices may only be added if they conform to Medicare laws
and regulations.]

2010 Evidence of Coverage for [insert plan name]
Chapter 9: Legal notices

SECTION 1

119

Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply
because they are required by law. This may affect your rights and responsibilities even if the
laws are not included or explained in this document. The principal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under the Social
Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other
Federal laws may apply and, under certain circumstances, the laws of the state you live in.

SECTION 2

Notice about nondiscrimination

We don’t discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed,
age, or national origin. All organizations that provide Medicare Advantage Plans, like our plan,
must obey federal laws against discrimination, including Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with
Disabilities Act, all other laws that apply to organizations that get Federal funding, and any other
laws and rules that apply for any other reason.

[Note: You may include other legal notices, such as a notice of member non-liability or a notice
about third party liability. These notices may only be added if they conform to Medicare laws
and regulations.]

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

120

CHAPTER 10: Definitions of important words
[Plans should insert definitions as appropriate to the plan type described in the EOC. You may
insert definitions not included in this model and exclude model definitions not applicable to your
plan, or to your contractual obligations with CMS or enrolled Medicare beneficiaries.]
Appeal – An appeal is something you do if you disagree with a decision to deny a request for
health care services or prescription drugs or payment for services or drugs you already received.
You may also make an appeal if you disagree with a decision to stop services that you are
receiving. For example, you may ask for an appeal if our Plan doesn’t pay for a drug, item, or
service you think you should be able to receive. Chapter 7 explains appeals, including the
process involved in making an appeal.
Brand-Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical
company that originally researched and developed the drug. Brand name drugs have the same
active-ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until after the
patent on the brand name drug has expired.
Catastrophic Coverage Stage – The stage in the Part D Drug Benefit where you pay a low
copayment or coinsurance for your drugs after you or other qualified parties on your behalf have
spent $[insert TrOOP amount] in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) – The Federal agency that runs Medicare.
Section 8 explains how to contact CMS.
Cost Group – Every drug on the list of covered drugs is in one of [insert number of cost groups]
Cost Groups. In general, the higher the Cost Group number, the higher your cost for the drug
Cost-sharing – Cost-sharing refers to amounts that a member has to pay when drugs are
received. It includes any combination of the following three types of payments: (1) any
deductible amount a plan may impose before drugs are covered; (2) any fixed “copayment”
amounts that a plan may require be paid when specific drugs are received; or (3) any
“coinsurance” amount that must be paid as a percentage of the total amount paid for a drug.
Coverage Determination – A decision about whether a medical service or drug prescribed for
you is covered by the plan and the amount, if any, you are required to pay. In general, if you
bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered
under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask
for a formal decision about the coverage if you disagree.
Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to cover, on average, at least as much as Medicare’s standard

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

121

prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll
in Medicare prescription drug coverage later.
Deductible – The amount you must pay before our plan begins to pay its share of your covered
medical services or drugs.
Disenroll or Disenrollment – The process of ending your membership in our plan.
Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Evidence of Coverage (EOC) and Disclosure Information – This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Exception – A type of coverage determination that, if approved, allows you to get a drug that is
not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at the
preferred cost-sharing level (a tiering exception). You may also request an exception if your plan
sponsor requires you to try another drug before receiving the drug you are requesting, or the plan
limits the quantity or dosage of the drug you are requesting (a formulary exception).
Generic Drug – A prescription drug that is approved by the Food and Drug Administration
(FDA) as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs
cost less than brand-name drugs.
Grievance – A type of complaint you make about us or one of our network pharmacies,
including a complaint concerning the quality of your care. This type of complaint does not
involve coverage or payment disputes.
Initial Coverage Limit – The maximum limit of coverage under the initial coverage period.
Initial Coverage Stage – This is the stage [insert if applicable: after you have met your
deductible and] before your total drug expenses, have reached $[insert initial coverage limit],
including amounts you’ve paid and what our plan has paid on your behalf.
Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug
coverage if you go without creditable coverage (coverage that expects to pay, on average, at least
as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or
more. You pay this higher amount as long as you have a Medicare drug plan. There are some
exceptions.
List of Covered Drugs (Formulary) – A list of covered drugs provided by the plan. The drugs
on this list are selected by the plan with the help of doctors and pharmacists. The list includes
both brand-name and generic drugs.

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

122

Low Income Subsidy/Extra Help – A Medicare program to help people with limited income
and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and
coinsurance.
Medically necessary – Drugs, services, or supplies that are proper and needed for the diagnosis
or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of
your medical condition; meet the standards of good medical practice in the local community; and
are not mainly for your convenience or that of your doctor.
Medicare – The Federal health insurance program for people 65 years of age or older, some
people under age 65 with certain disabilities, and people with End-Stage Renal Disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant).
Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a
private company that contracts with Medicare to provide you with all your Medicare Part A
(Hospital) and Part B (Medical) benefits. A MA plan offers a specific set of health benefits at the
same premium and level of cost-sharing to all people with Medicare who live in the service area
covered by the Plan. Medicare Advantage Organizations can offer one or more Medicare
Advantage plan in the same service area. A Medicare Advantage Plan can be an HMO, PPO, a
Private Fee-for-Service (PFFS) Plan, or a Medicare Medical Savings Account (MSA) plan. In
most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage).
These plans are called Medicare Advantage Plans with Prescription Drug Coverage.
Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health Plan that
is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions
apply).
[Insert Cost plan definition only if you are a Medicare Cost plan or there is one in your service
area.] Medicare Cost Plan – Cost plan means a plan operated by a Health Maintenance
Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed
contract under section 1876(h) of the Act.
Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for
outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare
Part A or Part B.
“Medigap” (Medicare supplement insurance) policy – Medicare supplement insurance sold by
private insurance companies to fill “gaps” in Original Medicare coverage. Medigap policies only
work with Original Medicare. (A Medicare Advantage plan is not a Medigap policy.)
Member (member of our Plan, or “plan member”) – A person with Medicare who is eligible
to get covered services, who has enrolled in our Plan and whose enrollment has been confirmed
by the Centers for Medicare & Medicaid Services (CMS).

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

123

Member Services – A department within our plan responsible for answering your questions
about your membership, benefits, grievances, and appeals. See Chapter 2 for information about
how to contact Member Services.
Network pharmacy – A network pharmacy is a pharmacy where members of our plan can get
their prescription drug benefits. We call them “network pharmacies” because they contract with
our plan. In most cases, your prescriptions are covered only if they are filled at one of our
network pharmacies.
[Include this definition only if plan has preferred and non-preferred pharmacies] [Insert either:
Non-preferred network pharmacy OR Other network pharmacy] – A network pharmacy that
offers covered drugs to members of our plan at higher cost-sharing levels than apply at a
preferred network pharmacy.
Original Medicare Plan – (“Traditional Medicare” or “Fee-for-service” Medicare) Original
Medicare is offered by the government, and not a private health plan like Medicare Advantage
plans and prescription drug plans. Under Original Medicare, Medicare services are covered by
paying doctors, hospitals and other health care providers payment amounts established by
Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare.
You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you
pay your share.
Out-of-network pharmacy – A pharmacy that doesn’t have a contract with our plan to
coordinate or provide covered drugs to members of our plan. As explained in this Evidence of
Coverage, most drugs you get from out-of-network pharmacies are not covered by our Plan
unless certain conditions apply.
Part C – see “Medicare Advantage (MA) Plan”
Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we
will refer to the prescription drug benefit program as Part D.)
Part D Drugs – Drugs that can be covered under Part D We may or may not offer all Part D
drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were
specifically excluded by Congress from being covered as Part D drugs.
[Include this definition only if plan has preferred and non-preferred pharmacies:] Preferred
Network Pharmacy – A network pharmacy that offers covered drugs to members of our plan at
lower cost-sharing levels than apply at a non-preferred network pharmacy.
Prior authorization – Approval in advance to get certain drugs that may or may not be on our
Drug List. Some drugs are covered only if your doctor or other network provider gets “prior
authorization” from us. Covered drugs that need prior authorization are marked in the Drug List.

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Definitions of important words

124

Quality Improvement Organization (QIO) – Groups of practicing doctors and other health
care experts that are paid by the Federal government to check and improve the care given to
Medicare patients. They must review your complaints about the quality of care given by
Medicare Providers. See Chapter 2 for information about how to contact the QIO in your state
and Chapter 5 for information about making complaints to the QIO.
Quantity Limits – A management tool that is designed to limit the use of selected drugs for
quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per
prescription or for a defined period of time.
Service area – “Service area” is the geographic area approved by the Centers for Medicare &
Medicaid Services (CMS) within which an eligible individual may enroll in a certain plan, and in
the case of network plans, where a network must be available to provide services.
Step Therapy – A utilization tool that requires you to first try another drug to treat your medical
condition before we will cover the drug your physician may have initially prescribed.
Supplemental Security Income (SSI) – A monthly benefit paid by the Social Security
Administration to people with limited income and resources who are disabled, blind, or age 65
and older. SSI benefits are not the same as Social Security benefits.