CMS-10260- Annual Notice of Change & Evidence of Coverage for Provi

Medicare Advantage and Prescription Drug Program: Final Marketing Provisions CFR 422.111(a)(3) and 423.128 (a)(3)

cover_and_EOC_Template_PFFS

Medicare Advantage and Prescription Drug Benefit Program: Final Marketing Provisions referenced in 42 CFR 422.111(a)(3) and 423.128(a)(3)

OMB: 0938-1051

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1051 can be found here:

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Annual Notice of Change & Evidence of
Coverage for Provider Fee‐for‐Service
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
( 30min) 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 switch to a different Medicare
Advantage Plan or to Original Medicare from November 15 through December 31 each
year. The Notice of Changes tells you more.
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 [insert as applicable: medical care OR medical care and prescription
drugs]. Please look through this document so you know what’s in it, then keep it handy
for reference.
3. [MA only plans delete this bullet:] We’re also including a copy of the [insert plan name]
plan’s 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
[insert as applicable: Medicare health care coverage, including your prescription drug coverage
OR Medicare health care 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, 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.”]
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 health plans in your area and with Original Medicare. You can see what plans
are available by visiting http://www.Medicare.gov. 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.
We are 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
Website: [insert URL]

[Plans may insert additional numbers, e.g., the
plan’s fax number or a number for callers who
speak Spanish.]
Do you need large print or another
format?
To get this material in other formats, including
large type, Braille, and translations in 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: MEDICAL SERVICES:
Changes to your benefits and what you pay ............................................ [x]
Changes to your benefits ........................................................................ [x]
Changes to what you pay ....................................................................... [x]
Section 4: 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 [X]: What about changes to the plan’s network of providers? ....... [x]
Will your doctors and other providers you use still be in the plan’s
network next year? ................................................................................ [x]
Section [X]: What if I don’t have drug coverage that is at
least as good as Medicare’s standard prescription
drug coverage? ..................................................................................... [x]
How do I know if I have drug coverage that is at least as good as
Medicare’s standard coverage? ........................................................ [x]
What are my options for getting Medicare prescription drug coverage? . [x]
Section [X]: 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 [X]: 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

Section 1. Important things to know
[Insert first subsection if plan is changing the plan name for the upcoming year:
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.”]
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 covered services
[insert if applicable: and prescription drugs]. (We sent you 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).

There are programs to help people with limited
resources pay for their prescription drugs
[MA-only plans delete this section.]
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.

Notice of Changes in [insert plan name] for 2010

•

[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?
[MA-only plans delete this section.]
[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]

[MA-only plans delete this paragraph.] 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 6 of your Evidence of
Coverage.

Section 3. Medical Services: Changes to your benefits
and what you pay
[If there are no changes in benefits or in cost-sharing, replace next two sections with: Our
benefits and what you pay for these covered services will be exactly the same in 2010 as it is in
2009.]
Changes to your benefits
[If there are no changes in benefits but changes in cost-sharing, replace text and table below with:
Our benefits will be exactly the same in 2010 as it is in 2009. However, there are some changes in

Notice of Changes in [insert plan name] for 2010

what you will pay for these covered services. See the next section for more information about the
change in what you pay for covered services.]
As shown below, [insert plan name] is [insert as appropriate: adding [a] new benefit[s] OR
ending [a] benefit[s] OR changing our covered benefits for] next year. For details, see Chapters 3
and 4 in your Evidence of Coverage.
[Plans list all new benefits that will be added or 2009 benefits that will be ended for 2010,
including any new optional supplemental benefits and the premiums for those benefits.]

[Insert benefit name]

2009 (this year)

2010 (next year)

[insert 2009 benefit,
e.g., “Not covered”]

[insert 2010
benefit, e.g.,
“Covered”]

Changes to what you pay
[If there are no changes in cost-sharing, replace text and table below with: The amount you pay
for covered services will be exactly the same in 2010 as it is in 2009.]
The chart below summarizes changes to what you will pay as your share of the cost of covered
medical services. For details, see Chapter 4, Medical benefits chart (what is covered and what
you pay), in your Evidence of Coverage.
[Plans list all changes in cost-sharing for 2010 for covered medical services.]

[Insert if applicable:] Out-ofpocket maximum for medical
services

2009 (this year)

2010 (next year)

[insert 2009 OOP
amount]

[insert 2010 OOP
amount]

[insert 2009 costsharing]

[insert 2010 costsharing]

[Insert description of what OOP
maximum applies to. E.g.: This
maximum applies to what you
pay as your share of the cost for
your Medicare Part A (Hospital
Insurance) and Medicare Part B
(Medical Insurance) services.]
[Insert benefit]

Notice of Changes in [insert plan name] for 2010

[Insert benefit]

[for coinsurance
amounts add: (you
pay xx% of the total
cost)]

[for coinsurance
amounts add:
(you pay xx% of
the total cost)]

[insert 2009 costsharing]

[insert 2010 costsharing]

[for coinsurance
amounts add: (you
pay xx% of the total
cost)]

[for coinsurance
amounts add:
(you pay xx% of
the total cost)]

Section 4. Part D Prescription Drugs: Changes to your
benefits and what you pay
[MA-only plans delete this Section.]
[If there are no changes in benefits or in cost-sharing, replace remainder of Section 4 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 5, 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 5, 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 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.

Notice of Changes in [insert plan name] for 2010

•

[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
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 OR copayment and 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

Notice of Changes in [insert plan name] for 2010

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 OR copayment and 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.

[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 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 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

Notice of Changes in [insert plan name] for 2010

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
for fewer days. Chapter 5, 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 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 9 (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 [X]. What about changes to the plan’s network
of providers?
[Plans with no provider network delete this Section.]
Will your doctors and other providers still be in the
plan’s network next year?
There are a few changes to the network of providers for 2010. In addition, it’s possible for the
network of plan providers to change at any time during the year.
•

Please check with your doctors and other providers you currently use to make sure
they will continue to be part of the provider network for [insert plan name] in 2010.

•

For the most up-to-date information on the network of providers, check our website
([insert URL]) or call Member Services (see phone numbers on the front cover).

Notice of Changes in [insert plan name] for 2010

Section [X]. What if I don’t have drug coverage that is at
least as good as Medicare’s standard prescription drug
coverage?
[MA-only plans insert this Section.]
How do I know if I have drug coverage that is at least as
good as Medicare’s standard coverage?
Our plan does not include Medicare prescription drug coverage. If you haven’t had other
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.) You will pay the penalty if you go without
creditable coverage for a continuous period of 63 days or more. The longer you wait to enroll in
a Medicare drug plan, the higher the penalty may be.
If you currently have other prescription drug coverage through your (or your spouse’s) employer
or retiree group, your employer or retiree group should send you a notice by November 15 that
tells if your prescription drug coverage is “creditable.” If you received a notice this year that you
no longer have creditable coverage, consider adding Medicare prescription drug coverage.
What are my options for getting Medicare prescription
drug coverage?
If you would like to get Medicare prescription drug coverage, you have many plan options. You
can keep our plan and get Medicare prescription drug coverage by joining a separate Medicare
drug plan. You can also switch to another Medicare Advantage plan that includes prescription
drug coverage. [MA plans offering other plans with Part D coverage, insert: Our organization
offers the following plans that include Medicare drug coverage: [insert list of plans with Part D
coverage available in the service area and Member Services contact below]]
To find other plans available in your area, visit http://www.medicare.gov and under “Search
Tools” select either “Compare Medicare Prescription Drug Plans” or “Compare Health Plans and
Medigap Policies in Your Area.” Or, call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
If you join another Medicare Advantage plan, you will be disenrolled from our plan when your
enrollment in the new plan begins.
Section [X]. Do you want to stay in the plan or make a
change?
Do you want to stay with [insert plan name]?

Notice of Changes in [insert plan name] for 2010

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 Advantage plan
or to Original Medicare (either with or without a separate Medicare prescription drug plan).
If you want to change to a different plan, there are many choices. As a reminder, [insert plan
name] offers other Medicare Advantage 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 [MA
plans, insert: any other Medicare Advantage plan or to Original Medicare (either with or
without a separate Medicare prescription drug plan).] Your new coverage will begin on
January 1, 2010.

•

You also have another, more limited enrollment period from January 1 through
March 31, 2010. [MA-PD plans insert: During this period (called the “open enrollment
period), you could switch to a different Medicare Advantage Plan with Part D
prescription drug coverage or switch to Original Medicare plus a Medicare Prescription
Drug Plan.] [MA-only plans insert: During this period (called the “open enrollment
period), you could switch to a different Medicare Advantage Plan without Part D
prescription drug coverage or switch to Original Medicare. (You cannot enroll in a
separate prescription drug plan during the Medicare Advantage Open Enrollment
Period.)] For more information about your choices during the January 1 through March
31 open enrollment period, please see Chapter 10, Section 2.2 of the Evidence of
Coverage.

Are these the only times of year to choose a different plan?
For most people, yes. Certain individuals, such as those with Medicaid, [insert if applicable:
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 10, Section 2.3
of the Evidence of Coverage.
How do you make a change?
See [insert as applicable: Chapter 8 OR Chapter 10] 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.

Notice of Changes in [insert plan name] for 2010

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.
• [MA only plans and 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 [X]. 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 [insert if applicable: 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
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].

Notice of Changes in [insert plan name] for 2010

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 (http://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 (http://www.medicare.gov) or by calling
1-800-MEDICARE (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 health coverage, [if
applicable: including your prescription drugs]
How to get the care you need

[Include plan contact information on the cover.]

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

Table of Contents

Chapter 1.

Getting started as a member of [insert plan name] ........................... [XX]
Tells what it means to be in a Medicare health 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 medical services ...................... [XX]
Explains important things you need to know about getting your medical care
as a member of our plan. Topics include using the providers in the plan’s
network and how to get care when you have an emergency.

Chapter 4.

Medical benefits chart (what is covered and what you pay) ............. [XX]
Gives the details about which types of medical care are covered and not
covered for you as a member of our plan. Tells how much you will pay as
your share of the cost for your covered medical care.

Chapter 5.

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.

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

Chapter 6.

What you pay for your Part D prescription drugs .............................. [XX]
Tells about the four stages of drug coverage (Deductible Stage, Initial
Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and
how these stages affect what you pay for your drugs. Explains the four Cost
Groups for your Part D drugs and tells what you must pay (copayments or
coinsurance) as your share of the cost for a drug in each Cost Group. Tells
about the late enrollment penalty.

Chapter 7.

Asking the plan to pay its share of a bill you have received
for medical services or drugs .............................................................. [XX]
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 covered services.

Chapter 8.

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 9.

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.
•

Explains how to ask for coverage decisions and make appeals if you are
having trouble getting the medical care or prescription drugs you think
are covered by our plan. This includes asking us to make exceptions to
the rules or extra restrictions on your coverage for prescription drugs, and
asking us to keep covering hospital care and certain types of medical
services if you think your coverage is ending too soon.

•

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

Chapter 10. 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 11. Legal notices ......................................................................................... [XX]
Includes notices about governing law and about nondiscrimination.
Chapter 12. Definitions of important words ............................................................ [XX]
Explain key terms used in this booklet.
[Other enclosures:]

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

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 three 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 Provider Directory: your guide to all providers in the plan’s network ........... [xx]

3.3

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

3.4

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

3.5

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

Introduction
What is the Evidence of Coverage
booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare medical care [insert if
applicable: and prescription drugs] 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 Medicare, and you have chosen to get your Medicare health care
[insert if applicable: and your prescription drug] coverage through our plan, [insert
plan name].

•

There are different types of Medicare Advantage Plans. [Insert plan name] is a
Medicare Advantage Plan PFFS (PFFS stand for Private Fee-for-Service).

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 services” refers to the medical care and services [insert if
applicable: and the prescription drugs] 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 services are 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]

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, [insert if applicable: 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
plan member?

Your three 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

•

-- and -- you are enrolled in Medicare Part B.

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

[PFFS plans offering Part D include this the following:
•

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.]

Chapter 1
Section 2.2

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 a 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

What other materials will you get from
us?

Your plan membership card – Use it to get
all covered care [insert if applicable: and
drugs]

While you are a member of our plan, you must use our membership card whenever you get any
services covered by this plan [insert if applicable: and 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.]
As long as you are a member of our plan you must not use your red, white, and blue
Medicare card to get covered medical services (with the exception of routine clinical research
studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in
case you need it later.
Here’s why this is so important: If you get covered services using your red, white, and blue
Medicare card instead of using our membership card while you are a plan member, you may
have to pay the full cost yourself.
If your plan membership card is damaged, lost, or stolen, call Member Services right away and
we will send you a new card.

Chapter 1
Section 3.2

The Provider Directory: your guide to all
providers in the plan’s network

[Note: plans without a provider network exclude following paragraph.]
[Note: Network PFFS plans should include this section.]
Every year that you are a member of our plan, we will send you either a new Provider Directory
or an update to your Provider Directory. This directory lists our network providers.

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

What are “network providers”?
Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that participate in our plan with whom we have written
contracts to deliver covered services to members in our plan.
Why do you need to know which providers are part of our network?
There are several reasons why it is important for you to know whether our plan uses a network
and if so, which providers are part of the network: (1) A network provider must furnish you care
while an out-of-network provider has the right to refuse to treat you; (2) A network provider
frequently charges less cost-sharing than an out-of-network provider; (3) If our plan choose to
have a network, we must provide a sufficient number and range of providers to meet your needs.
These requirements are over and above the access standards used by Original Medicare.

[Note: plans without a provider directory exclude following paragraph.]
If you don’t have your copy of the Provider Directory, you can request a copy from Member
Services. You may ask Member Services for more information about our network providers,
including their qualifications. [Plans may add additional information describing the information
available in the provider directory, on the plan’s website, or from Member Services. For
example: You can also see the Provider Directory at [insert URL], or download it from this
website. Both Member Services and the website can give you the most up-to-date information
about changes in our network providers.]
Chapter 1
Section 3.3

The Pharmacy Directory: your guide to
pharmacies in our network

[PFFS plans without Part D coverage may omit this section.]
[Plans with combined provider and pharmacy directories may edit the provider and pharmacy
directory paragraphs to describe the combined document.]
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.

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

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.
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 3.4

The plan’s List of Covered Drugs
(Formulary)

[PFFS plans without Part D coverage may omit this section.]
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 plan’s 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 3.5

Reports with a summary of payments
made for your prescription drugs

[PFFS plans without Part D coverage may omit this section.]
When you use your prescription drug benefits, we will send a monthly 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
6 (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.
[Note: Plans may insert other methods that members can get their Explanation of Benefits.]

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

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
[insert year], 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.]
[Plans with no premium should replace the preceding paragraph with: You do not pay a
separate monthly plan premium for [insert plan name].]
[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]
[Plans with no monthly premium: Omit this subsection.]
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].
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]
[Insert if applicable: If you signed up for extra benefits, also called “optional supplemental
benefits”, then you pay an additional premium each month for these extra benefits. If you have
any questions about your plan premiums, please call Member Services.]
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

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

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 6, Section 9 explains the late
enrollment penalty.
Many members are required to pay other Medicare premiums
[Plans that include a Part B premium reduction benefit may describe the benefit within this
section.]
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 http://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
[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.]

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

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
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, you will have coverage under Original Medicare. 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?

[Plans without a monthly premium may delete this section.]

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

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
will need to start paying their full monthly premium. You can find out more about Extra Help in
Chapter 2, Section 7.
[Plans without Part D coverage omit]:
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.”]

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

Your membership record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage [insert as appropriate: including your
Primary Care Provider/Medical Group/IPA].
The doctors, hospitals, [insert if applicable: pharmacists,] and other providers in the plan’s
network need to have correct information about you. These network providers use your
membership record to know what services [insert if applicable: and 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 health insurance coverage you have (such as from your employer,
your spouse’s employer, workers’ compensation, or Medicaid)

•

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

•

If you have been admitted to a nursing home

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 [insert if applicable: and
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

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

[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

[Note: If your plan uses the same contact information for the Part C and Part D issues indicated
below, you may combine the appropriate sections.]
How to contact us when you are asking for a coverage
decision about your medical care
[Insert plan name] Coverage Decisions for Medical Care
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 organization
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
organization determinations, also include that number here.]
[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited organization determinations, also
include that number here.]
[Insert address] [Note: If you have a different address for accepting
expedited organization determinations, also include that number
here.]

For more information on asking for coverage decisions about your medical care, see Chapter
9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
How to contact us when you making an appeal about your
medical care
[Insert plan name] Appeals for Medical Care
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

[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 number here.]

For more information on making an appeal about your medical care, see Chapter 9 (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 medical care
[Insert plan name] Complaints about Medical Care
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 number 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 medical care, see Chapter 9 (What
to do if you have a problem or complaint (coverage decisions, appeals, complaints).
How to contact us when you are asking for a coverage
decision about your Part D prescription drugs
[Note: PFFS plan not offering Part D may delete this table.]
[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 number here.]

For more information on asking for coverage decisions about your Part D prescription drugs,
see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints).

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

How to contact us when you are making an appeal about your
Part D prescription drugs
[Note: PFFS plan not offering Part D may delete this Part D table.]
[Insert plan name] Appeals 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 appeals, 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

For more information on making an appeal about your Part D prescription drugs, see Chapter
9 (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
[Note: PFFS plan not offering Part D may delete this Part D table.]
[Insert plan name] Complaints about Part D prescription drugs
CALL

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

TTY/TDD

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

FAX

WRITE

For more information on making a complaint about your Part D prescription drugs, see
Chapter 9 (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 for medical care [insert if applicable: or a drug] 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 7
(Asking the plan to pay its share of a bill you have received for medical services or
drugs).
[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

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

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

SECTION 2

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 health plans
including [insert plan name].
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.

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

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
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]

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

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.]
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 made a complaint to our plan and you don’t like our response to your complaint.
You think coverage for your hospital stay is ending too soon.
You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services 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]

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

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.
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

http://www.ssa.gov

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

SECTION 6

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
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, yearly

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

deductible, and prescription copayments. This Extra Help also counts toward your out-ofpocket 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
[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]

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

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
CALL

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 benefits, premiums, or the
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 medical services

CHAPTER 3: Using the plan’s coverage for your medical services

SECTION 1. Summary of things to know about getting your
medical care as a member of our plan
1.1

What are “network providers” and “covered services”? ........................................ [xx]

1.2

Basic rules for getting your medical care that is covered by the plan ..................... [xx]

SECTION 2. Use providers in the plan’s network to get your medical care
2.1

You must choose a Primary Care Provider (PCP) to provide and arrange for
your medical care ................................................................................................. [xx]

2.2

How to get care from specialists and other network providers ............................... [xx]

2.3

What kinds of medical care can you get without getting approval in advance
from your PCP? .................................................................................................... [xx]

SECTION 3. How to get covered services when you have an
emergency
3.1

Getting care if you have a medical emergency ...................................................... [xx]

SECTION 4. What if you are billed directly for the full cost of your
covered services?
4.1

How to ask the plan to pay its share of the cost of your covered services .............. [xx]

4.2

If services are not covered by our plan, you must pay the full cost ........................ [xx]

SECTION 5. How are your medical services covered when you are
in a “clinical research study”?
5.1

What is a “clinical research study”? ...................................................................... [xx]

5.2

When you participate in a clinical research study, who pays for what? .................. [xx]

SECTION 6. Rules for getting care in a “religious non-medical health
care institution”
6.1

What is a religious non-medical health care institution? ........................................ [xx]

6.2

What care from a religious non-medical health care institution is covered by
our plan?............................................................................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

SECTION 1

Summary of things to know about getting
your medical care as a member of our
plan

This chapter tells things you need to know about using [insert plan name] to get your medical
care. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, and other medical care that are covered by the plan.
For the details on what medical care is covered by our plan and how much you pay as your
share of the cost when you get this care, use the benefits chart in the next chapter, Chapter 4
(Medical benefits chart, what is covered and what you pay).

Chapter 3
Section 1.1

What [is/are] [for network PFFS insert:
“network providers” and] “covered
services”?

Here are some definitions that can help you understand how you get the care and services that
are covered for you as a member of our plan:
•

“Providers” are doctors and other health care professionals that the state licenses to
provide medical services and care. The term “providers” also includes hospitals and other
health care facilities.

•

[For network PFFS plans insert:] “Network providers” are the doctors and other health
care professionals, medical groups, hospitals, and other health care facilities that
participate in our plan. We have arranged for these providers to deliver covered services
to members in our plan.

•

“Covered services” include all the medical care, health care services, supplies, and
equipment that are covered by our plan. Your covered services for medical care are listed
in the benefits chart in Chapter 4.

Chapter 3
Section 1.2

Basic rules for getting your medical care
that is covered by the plan

[Insert plan name] will generally cover your medical care as long as:
•
•

The care you receive is included in the plan’s Medical Benefits Chart (this chart is in
Chapter 4 of this booklet).
The care you receive is considered medically necessary. It needs to be accepted
treatment for your medical condition.

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

•

You can receive your care from any provider in the United States, if the provider is
eligible to be paid by Medicare and agrees to accept our plan’s terms and conditions of
payment prior to providing services to you.
o You must show your plan membership card every time you visit a provider. A
provider can decide at every visit to accept our plan’s terms and conditions, and
thus treat you. A provider cannot change his/her mind about accepting the payment
terms after providing services.
o If you need emergency care, it is covered whether a provider agrees to accept the
plan’s payment terms or not.
o Not all providers accept our plan’s terms and conditions of payment or agree to
treat you. If a provider from whom you seek care refuses to treat you, or if a
provider you have been regularly seeing refuses to continue providing you care,
then you will need to find another provider that will accept our plan’s payment
terms.

•

You are required to pay only the copayment or coinsurance amount allowed by our
plan at the time of the visit. You should ask the provider to bill the plan for your
covered services. If provider asks you to pay the full amount of the services, and have
you paid back by the plan, remind the provider that you are only responsible for the costsharing amount. If the provider wants further information on payment for covered
services, please have the provider contact us at [Note: insert instructions that include a
phone number and mailing address].

•

[Note to Network PFFS: adapt the following language for the network PFFS plan that is
being offered: “Our Plan has direct contracts with some providers to provide you with
health care services.”]
o [Note: Plan should describe what category or categories of providers it has
under direct contract that were approved by CMS and whether or not the Plan
has established any higher cost-sharing requirement if the member obtains a
covered service from a deemed provider. Insert the following sentence if the plan
includes such differential cost-sharing: “Note that the amount of cost-sharing you
pay a non-contracted provider may be more than the cost-sharing you pay a
contracted provider.”]

SECTION 2

Use providers in the plan’s network to get
your medical care

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

Chapter 3
Section 2.1

How to get care from specialists and
other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the
body. There are many kinds of specialists. Here are a few examples:
•
•
•

Oncologists, who care for patients with cancer.
Cardiologists, who care for patients with heart conditions.
Orthopedists, who care for patients with certain bone, joint, or muscle conditions.

What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the
plan. [Plans should describe what to do if their specialist or other provider leaves the network.]

SECTION 3

Chapter 3
Section 3.1

How to get covered services when you
have an emergency

Getting care if you have a
medical emergency

[Note: Throughout this section plans can change “notify plan” to provider, medical group or
any other specific area the member should call after an emergency.]
What is a “medical emergency” and what should you do if you have one?
When you have a “medical emergency,” you believe that your health is in serious danger. A
medical emergency can include severe pain, a bad injury, a sudden illness, or a medical condition
that is quickly getting much worse.
If you have a medical emergency:

• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room,
hospital, or urgent care center. Call for an ambulance if you need it. You do not need to
get approval or [insert if applicable: a referral first from your PCP].

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

• As soon as possible, make sure that our plan has been told about your emergency.
We need to follow up on your emergency care. [Plans must provider either the number to
call or explain where to find the number (e.g., on the back the plan membership card).]
What is covered if you have a medical emergency?
You may get covered emergency medical care whenever you need it, anywhere in the United
States. (In very limited circumstances emergency services are covered in Canada. If you have an
emergency in Canada, call your plan to find out if you are eligible for coverage for emergency
services.) Our plan covers ambulance services in situations where getting to the emergency room
in any other way could endanger your health. For more information, see the medical benefits
chart in Chapter 4 of this booklet.
[Plans that offer a supplemental benefit covering emergencies or ambulance services outside of
the country, mention the benefit here and then refer members to Chapter 4 for more
information.]
If you have an emergency, we will talk with the doctors who are giving you emergency care
to help manage and follow up on your care. The doctors who are giving you emergency care
will decide when your condition is stable and the medical emergency is over.
What if it wasn’t a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it wasn’t a medical emergency after all.
If you decide to get follow-up care from the provider treating you, then you should advise them
of your plan enrollment as soon as possible, by showing them your membership ID card. The
plan will pay for all medically-necessary plan-covered services furnished by the provider and
non-emergency care that you get from any provider in the United States who agrees to accept our
plan’s terms and conditions of payment.

SECTION 4

Chapter 3
Section 4.1

What if you are billed directly for the full
cost of your covered services?

You can ask the plan to pay our
share of the cost of your covered
services

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

Sometimes when you get medical care, 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 will want our plan to pay our share of the costs by reimbursing you for
payments you have already made.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received. In many cases, you should send this bill to us so that we can pay our share
of the costs for your covered medical services.
If you have paid more than your share for covered services, or if you have received a bill for the
full cost of covered medical services, go to Chapter 7, Section 2.3 for information about what to
do.
Chapter 3
Section 4.2

If services are not covered by our plan,
you must pay the full cost

[Insert plan name] covers all medical services that are medically necessary and are covered
under Medicare. You are responsible for paying the full cost of services that aren’t covered by
our plan.
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. If we say we
will not cover your services, you have the right to appeal our decision not to cover your care.
Chapter 9 (What to do if you have a problem or complaint) has more information about what to
do if you want a coverage decision from us or want to appeal a decision we have already made.
You may also call Member Services at the number on the front cover of this booklet to get more
information about how to do this.
For covered services that have a benefit limitation, you pay the full cost of any services you get
after you have used up your benefit for that type of covered service. [Plans should explain
whether paying for costs once a benefit limit has been reached will count toward an out-ofpocket maximum.] You can call Members Services when you want to know how much of your
benefit limit you have already used.

SECTION 5

How are your medical services covered
when you are in a “clinical research
study”?

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

Chapter 3
Section 5.1

What is a “clinical research study”?

A clinical research study is a way that doctors and scientists test new types of medical care, like
how well a new cancer drug works. They test new medical care procedures or drugs by asking
for volunteers to help with the study. This kind of study is one of the final stages of a research
process that helps doctors and scientists see if a new approach works and if it is safe.
Not all clinical research studies are open to members of our plan. Medicare first needs to approve
the research study. If you participate in a study that Medicare has not approved, you will be
responsible for paying all costs for your participation in the study.
If you participate in a Medicare-approved study, Original Medicare pays the doctors and other
providers for the covered services you receive as part of the study. When you are in a clinical
research study, you may stay enrolled in our plan and continue to get the rest of your care (the
care that is not related to the study) through our plan.
If you want to participate in a Medicare-approved clinical research study, you do not need to get
approval from our plan or your PCP. The providers that deliver your care as part of the clinical
research study do not need to be part of our plan’s network of providers.
Although you do not need to get our plan’s permission to be in a clinical research study, you do
need to tell us before you start participating in a clinical research study. Here is why you
need to tell us:
1. We can let you know whether the clinical research study is Medicare-approved.
2. We can tell you what services you will get from clinical research study providers instead
of from our plan.
3. We can keep track of the health care services that you receive as part of the study.
If you plan on participating in a clinical research study, contact 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].
Chapter 3
Section 5.2

When you participate in a clinical
research study, who pays for what?

Once you join a Medicare-approved clinical research study, Medicare will pay for the covered
services you receive as part of the research study. Medicare pays for routine costs of items
and services. Examples of these items and services include the following:

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

•
•
•

Room and board for a hospital stay that Medicare would pay for even if you weren’t in a
study.
An operation or other medical procedure if it is part of the research study.
Treatment of side effects and complications of the new care.

When you are part of a clinical research study, Medicare will not pay for any of the following:
•
•
•

Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.
Items and services the study gives you or any participant for free.
Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your condition would usually require only one CT scan.

[If your plan charges Original Medicare’s cost-sharing amounts for clinical trial services, use
this language: You will have to pay the same coinsurance amounts charged under Original
Medicare for the services you receive as a participant in the clinical research study. Because you
are a member of our plan, you do not have to pay the deductibles for Original Medicare Part A or
Part B.]
[If your plan will cover all or a portion of the FFS coinsurance for your members participating
in a clinical trial, say so here and/or modify the previous sentences. Also, specify the conditions
(if any) under which such additional coverage is available (e.g., if the member participants in a
clinical trial sponsored by one of your contracting providers).]
Do you want to know more?
To find out what your coinsurance would be if you joined a Medicare-approved clinical research
study, please call us at Member Services (phone numbers are on the cover of this booklet).
You can get more information about joining a clinical research study by reading the publication
“Medicare and Clinical Research Studies” at
http://www.medicare.gov/Publications/Pubs/pdf/02226.pdf. You can also call 1-800MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-4862048.

SECTION 6

Rules for getting care in a
“religious non-medical health care
institution”

2010 Evidence of Coverage for [insert plan name]
Chapter 3: Using the plan’s coverage for your medical services

Chapter 3
Section 6.1

What is a religious non-medical health
care institution?

A religious non-medical health care institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a
hospital or a skilled nursing facility is against a member’s religious beliefs, you must elect to
have your coverage for care in a religious non-medical health care institution. You may also
chose at any time if for any reason you decide to pursue medical care. This benefit provides only
for Part A inpatient services. Medicare will only pay for non-medical health care services
furnished by religious non-medical health care institution.
Chapter 3
Section 6.2

What care from a religious non-medical
health care institution is covered by our
plan?

To get care from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical treatment that is “non-excepted.”
• “Non-excepted” medical care or treatment is any medical care or treatment that is
voluntary and not required by any federal, state, or local law.
• (“Excepted” medical treatment is medical care or treatment that you get that is not
voluntary or is required under federal, state, or local law.)
To be covered by our plan, the care you get from a religious non-medical health care institution
must meet the following conditions:
•

The facility providing the care must be certified by Medicare.

•

Our plan’s coverage of services you receive is limited to non-religious aspects of care.

•

If you get services from this institution that are provided to you in your home, our plan
will cover these services only if they are the kind of services that would ordinarily be
given by home health agencies that are not religious non-medical health care institutions.

•

If you get services from this institution that are provided to you in a facility, the
following [insert as applicable: conditions apply OR condition applies]:
o You must have a medical condition that would allow you to receive covered
services for inpatient hospital care or skilled nursing facility care.
o [Omit this bullet if not applicable] – and – you must get approval in advance from
our plan before you are admitted to the facility or your stay will not be covered.

[Plans must explain whether Medicare Inpatient Hospital coverage limits apply (include a
reference to the benefits chart in Chapter 4) or whether there is unlimited coverage for this
benefit.]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

CHAPTER 4: Medical benefits chart (what is covered and what you pay)

SECTION 1. Understanding your out-of-pocket costs for
covered services
1.1

What types of out-of-pocket costs do you pay for your covered services? ............. [xx]

1.2

What is the maximum amount you will pay for certain covered medical
services? ............................................................................................................... [xx]

SECTION 2. Use this Medical Benefits Chart to find out what is
covered for you and how much you will pay
2.1

Your medical benefits and costs as a member of the plan ...................................... [xx]

2.2

Extra “optional supplemental” benefit you can buy ............................................... [xx]

SECTION 3. What types of benefits are not covered by the plan?
3.1

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

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

SECTION 1

Understanding your out-of-pocket costs for
covered services

This chapter focuses on your covered services and what your pay for you medical benefits. It
includes a Medical Benefits Chart that gives a list of your covered services and tells how much
you will pay for each covered service as a member of [insert plan name]. Later in this chapter,
you can find information about medical services that are not covered. [Insert if applicable: It also
tells about limitations on certain services.] [If applicable, you may mention other places where
benefits, limitations, and exclusions are described, such as optional additional benefits, or
addenda.]
Chapter 4
Section 1.1

What types of out-of-pocket costs do you
pay for your covered services?

[Describe all applicable cost-sharing types your plan uses. You may omit those that are not
applicable.]
To understand the payment information we give you in this chapter, you need to know about the
types of out-of-pocket costs you may pay for your covered services.
•

The “deductible” means the amount you must pay for medical services before our plan
begins to pay its share.

•

A “copayment” means that you pay a fixed amount each time you receive a medical
service. You pay a copayment at the time you get the medical service.

•

“Coinsurance” means that you pay a percent of the total cost of a medical service. You
pay a coinsurance at the time you get the medical service.

Some people qualify for programs to help them pay their out-of-pocket costs for Medicare. If
you are enrolled in these programs, you may still have to pay the Medicaid copayment,
depending on the rules in your state.

Chapter 4
Section 1.2

What is the maximum amount you will pay
for certain covered medical services?

There is a limit to how much you have to pay out-of-pocket for certain covered health care
services each year. [Plans with out-of-pocket limit should describe what services the OOP max
applies to, including dollar amounts. Plans may choose to do so using notations within the
benefits chart.]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

[Section 2 should be deleted if the plan does not have an out-of-pocket limit.]

SECTION 2

Chapter 4
Section 2.1

Use this Medical Benefits Chart to find out
what is covered for you and how much
you will pay

Your medical benefits and costs as a
member of the plan

The medical benefits chart on the following pages lists the services [insert plan name] covers
and what you pay for each service. The services listed in the Medical Benefits Chart are covered
only when all coverage requirements are met:
•

Your Medicare covered services must be provided according to the coverage guidelines
established by Medicare.

•

Except in the case of preventative services and screening tests, your services (including
medical care, services, supplies, and equipment) must be medically necessary. Medically
necessary means that the services are an accepted treatment for your medical condition.

•

[Note: adapt the following language for the PFFS plan that has established prior
notification requirements: “Our Plan has prior notification requirements when you
receive certain health care services from a provider.”][Note: Plan should describe what
health care services have prior notification requirements and whether or not the Plan
has established any higher cost-sharing requirement if the member or provider does not
notify the plan before the service is furnished. Insert the following sentence if the plan
includes such differential cost-sharing: “Note that the amount of cost-sharing you pay if
you do not prior notify our plan may be more than the cost-sharing you pay when you
prior notify.”]

•

[Insert if applicable: You receive your care from a network provider. In most cases, care
you receive from a non-network provider will not be covered. Chapter 3 provides more
information about requirements for using network providers and the situations when we
will cover services from a non-network provider.]

•

You may receive plan-covered services from any provider who agrees to accept the
terms and conditions of payment of our plan. A provider is considered to have agreed to
accept the terms and conditions of payment if they knew you are a member of the PFFS
plan (for example if you showed them your PFFS plan card) and they had the
opportunity to read the terms and conditions of payment. The provider doesn't have to
actually read the terms and conditions of payment. Rather if (s)he had the opportunity to
read them then as soon as (s)he treats you, the law deems this provider as if (s)he had
signed a contract.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

[insert list]
[Instructions on completing benefits chart:
• When preparing this Benefits Chart, please refer to any instructions contained in the
cover memorandum of the standardized/combined ANOC/EOC.
• All plans with networks should clearly indicate for each service applicable the difference
in cost-sharing at network and out-of-network providers and facilities.
• Plans should clearly indicate which benefits are subject to prior authorization (plans may
use asterisks or similar method).
• Plans may insert any additional benefits information based on the plan’s approved bid
that is not captured in the benefits chart or in the exclusions section.]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

Inpatient Care
Inpatient hospital care
[List days covered and any restrictions that apply.] Covered services
include:

•
•
•
•
•
•
•
•
•
•
•
•

Semi-private room (or a private room if medically necessary)
Meals including special diets
Regular nursing services
Costs of special care units (e.g., intensive or coronary care units)
Drugs and medications
Lab tests
X-rays and other radiology services
Necessary surgical and medical supplies
Use of appliances, such as wheelchairs
Operating and recovery room costs
Physical, occupational, and speech language therapy
Under certain conditions, the following types of transplants are
covered: corneal, kidney, kidney-pancreatic, heart, liver, lung,
heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If
you need a transplant, we will arrange to have your case reviewed
by a Medicare-approved transplant center that will decide
whether you are a candidate for a transplant. [Network plans
insert: If you are sent outside of your community for a transplant,
we will arrange or pay for appropriate lodging and transportation
costs for you and a companion.] [Plans may further define the
specifics of transplant travel coverage.]

• Blood - including storage and administration. Coverage of whole
blood and packed red cells begins only with the fourth pint of
blood that you need - you pay for the first 3 pints of unreplaced
blood. All other components of blood are covered beginning with
the first pint used. [Modify as necessary if the plan begins
coverage with an earlier pint.]

• Physician Services

[List copayments/
coinsurance. If costsharing is based on
benefit period, include
definition/
explanation of BID
approved benefit
period here. Plans
that use a peradmission deductible,
include: A per
admission deductible
is applied once during
a benefit period.]
[Non-network PFFS
can disregard the
next paragraph:] If
you get [insert of
applicable:
authorized] inpatient
care at a non-plan
hospital after your
emergency condition
is stabilized, your
cost is the [Insert if
applicable: highest]
cost-sharing you
would pay at a plan
hospital.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

Inpatient mental health care

• Covered services include mental health care services that require a
hospital stay. [List days covered, restrictions such as 190-day
lifetime limit for inpatient services in a psychiatric hospital. The
190-day limit does not apply to Mental Health services provided in
a psychiatric unit of a general hospital.]

[List copays /
coinsurance. If costsharing is based on
benefit period,
include definition/
explanation of BID
approved benefit
period here.]

Skilled nursing facility (SNF) care
(For a definition of “skilled nursing facility,” see Chapter 12 of this
booklet. Skilled nursing facilities are sometimes called “SNFs.”)
[List days covered and any restrictions that apply, including whether any
prior hospital stay is required.] Covered services include:

•
•
•
•
•

Semiprivate room (or a private room if medically necessary)
Meals, including special diets
Regular nursing services
Physical therapy, occupational therapy, and speech therapy
Drugs administered to you as part of your plan of care (This
includes substances that are naturally present in the body, such as
blood clotting factors.)

•
•
•
•

Medical and surgical supplies ordinarily provided by SNFs
Laboratory tests ordinarily provided by SNFs
X-rays and other radiology services ordinarily provided by SNFs
Use of appliances such as wheelchairs ordinarily provided by
SNFs

[List copays/
coinsurance. If costsharing is based on
benefit period, include
definition/explanation
of BID approved
benefit period here.]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

• Physician services
Inpatient services covered when the hospital or SNF days
aren’t, or are no longer, covered

[List copays/
coinsurance]

Covered services include:

• Physician services
• Tests (like X-ray or lab tests)
• X-ray, radium, and isotope therapy including technician materials
and services

• Surgical dressings, splints, casts and other devices used to reduce
fractures and dislocations

• Prosthetics and orthotics devices (other than dental) that replace
all or part of an internal body organ (including contiguous tissue),
or all or part of the function of a permanently inoperative or
malfunctioning internal body organ, including replacement or
repairs of such devices

• Leg, arm, back, and neck braces; trusses, and artificial legs, arms,
and eyes including adjustments, repairs, and replacements
required because of breakage, wear, loss, or a change in the
patient’s physical condition

• Physical therapy, speech therapy, and occupational therapy
Home health agency care
Covered services include:

• Part-time or intermittent skilled nursing and home health aide

•
•
•

services (To be covered under the home health care benefit, your
skilled nursing and home health aide services combined must
total fewer than 8 hours per day and 35 hours per week)
Physical therapy, occupational therapy, and speech therapy
Medical social services
Medical equipment and supplies

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

Hospice care
You may receive care from any Medicare-certified hospice program.
Original Medicare (rather than our Plan) will pay the hospice provider
for the services you receive. [Insert if applicable: Your hospice doctor
can be a network provider or an out-of-network provider.] You will still
be a plan member and will continue to get the rest of your care that is
unrelated to your terminal condition through our Plan. Covered services
include:

• Drugs for symptom control and pain relief, short-term respite
care, and other services not otherwise covered by Original
Medicare

• Home care
[Insert if applicable, edit as appropriate: Our plan covers hospice
consultation services (one time only) for a terminally ill person who
hasn’t elected the hospice benefit.]

When you enroll in a
Medicare-certified
hospice program, your
hospice services are
paid for by the
Original Medicare
Plan, not [insert plan
name].
[Include information
about cost-sharing for
hospice consultation
services if
applicable.]

Outpatient Services
Physician services, including doctor’s office visits
Covered services include:

• Office visits, including medical and surgical care in a physician’s
office or certified ambulatory surgical center

• Consultation, diagnosis, and treatment by a specialist
• Hearing and balance exams, if your doctor orders it to see if you
need medical treatment.

• Telehealth office visits including consultation, diagnosis and
treatment by a specialist

• Second opinion [Insert in appropriate: by another network
provider] prior to surgery

• Outpatient hospital services
• Non-routine dental care (covered services are limited to surgery
of the jaw or related structures, setting fractures of the jaw or
facial bones, extraction of teeth to prepare the jaw for radiation

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

treatments of neoplastic cancer disease, or services that would be
covered when provided by a doctor)
[Also list any additional benefits offered.]
Chiropractic services
Covered services include:

• Manual manipulation of the spine to correct subluxation

[List copays/
coinsurance]

[Also list any additional benefits offered.]
Podiatry services
Covered services include:

[List copays/
coinsurance]

• Treatment of injuries and diseases of the feet (such as hammer toe
or heel spurs).

• Routine foot care for members with certain medical conditions
affecting the lower limbs
[Also list any additional benefits offered.]
Outpatient mental health care, including partial
hospitalization services
Covered services include:

[List copays/
coinsurance]

• Mental health services provided by a doctor, clinical
psychologist, clinical social worker, clinical nurse specialist,
nurse practitioner, physician assistant, or other Medicarequalified mental health care professional as allowed under
applicable state laws.
• “Partial hospitalization” is a structured program of active
treatment that is more intense than the care received in your
doctor’s or therapist’s office and is an alternative to inpatient
hospitalization.
[Also list any additional benefits offered.]
Outpatient substance abuse services

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

Outpatient surgery, including services provided at
ambulatory surgical centers

What you must
pay when you get
these services
[List copays/
coinsurance]

Ambulance services
Covered ambulance services include fixed wing, rotary wing, and ground
ambulance services, to the nearest appropriate facility that can provide
care only if they are furnished to a member whose medical condition is
such that other means of transportation are contraindicated (could
endanger the person’s health). The member’s condition must require
both the ambulance transportation itself and the level of service provided
in order for the billed service to be considered medically necessary.
Non-emergency transportation by ambulance is appropriate if it is
documented that the member’s condition is such that other means of
transportation are contraindicated (could endanger the person’s health)
and that transportation by ambulance is medically required.

[List copays /
coinsurance. Specify
whether cost-sharing
applies one-way or
for round trips.]

Emergency care
[Identify whether this coverage is limited to the U.S. or is also available
world-wide.]

[List copays /
coinsurance. If
applicable, explain
that cost-sharing is
waived if member
admitted to hospital.]
[Non-network PFFS
plans can disregard
the next paragraph.]
If you need inpatient
care at an out-ofnetwork hospital after
your emergency
condition is stabilized,
[Insert one or both:
you must return to a
network hospital in
order for your care to
continue to be
covered OR you must

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services
have your inpatient
care at the out-ofnetwork hospital
authorized by the plan
and your cost is the
[Insert if applicable:
highest] cost-sharing
you would pay at a
network hospital.]

Comprehensive Outpatient Rehabilitation Facility (CORF)
services
Covered services include: Covered services include: physical therapy,
occupational therapy, speech language therapy, and cardiac
rehabilitative therapy

[List copays/
coinsurance]

Durable medical equipment and related supplies
(For a definition of “durable medical equipment,” see Chapter 12 of this
booklet.)

[List copays/
coinsurance]

Covered items include, but are not limited to wheelchairs, crutches,
hospital bed, IV infusion pump, oxygen equipment, nebulizer, and
walker.
Prosthetic devices and related supplies
Devices (other than dental) that replace a body part or function. These
include, but are not limited to colostomy bags and supplies directly
related to colostomy care, pacemakers, braces, prosthetic shoes, artificial
limbs, and breast prostheses (including a surgical brassiere after a
mastectomy). Includes certain supplies related to prosthetic devices, and
repair and/or replacement of prosthetic devices. Also includes some
coverage following cataract removal or cataract surgery – see “Vision
Care” later in this section for more detail.

[List copays/
coinsurance]

Diabetes self-monitoring, training, and supplies
For all people who have diabetes (insulin and non-insulin users).
Covered services include:

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

• Blood glucose monitor, blood glucose test strips, lancet devices
and lancets, and glucose-control solutions for checking the
accuracy of test strips and monitors

• One pair per calendar year of therapeutic custom-molded shoes
(including inserts provided with such shoes) and two additional
pairs of inserts, or one pair of depth shoes and three pairs of
inserts (not including the non-customized removable inserts
provided with such shoes) for people with diabetes who have
severe diabetic foot disease. Coverage includes fitting.

• Self-management training is covered under certain conditions
• For persons at risk of diabetes: Fasting plasma glucose tests.
[Insert frequency]
[Also list any additional benefits offered.]
Medical nutrition therapy
For people with diabetes, renal (kidney) disease (but not on dialysis),
and after a transplant when referred by your doctor.
Outpatient diagnostic tests and therapeutic services and
supplies
Covered services include:

• X-rays
• Radiation therapy [List separately any services for which a
separate co-pay/coinsurance applies over and above the
outpatient radiation therapy co-pay/coinsurance.]

•
•
•
•

Surgical supplies, such as dressings
Supplies, such as splints and casts
Laboratory tests
Blood. Coverage begins with the fourth pint of blood that you
need – you pay for the first 3 pints of unreplaced blood. [Modify
as necessary if the plan begins coverage with an earlier pint.]
Coverage of storage and administration begins with the first pint
of blood that you need.

• Other outpatient diagnostic tests [Plans can include other covered

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

tests as appropriate]
Vision care
Covered services include:

• Outpatient physician services for eye care.
• For people who are at high risk of glaucoma, such as people with

[List copays/
coinsurance]

a family history of glaucoma, people with diabetes, and AfricanAmericans who are age 50 and older: glaucoma screening once
per year

• [Adapt this description if the plan offers more than is covered by
Original Medicare.] One pair of eyeglasses or contact lenses after
each cataract surgery that includes insertion of an intraocular
lens. Corrective lenses/frames (and replacements) needed after a
cataract removal without a lens implant.
[Also list any additional benefits offered, such as routine vision
exams or glasses, either here or in “Vision Care” section later in
benefits chart.]

Preventive Care and Screening Tests
[For all preventive care and screening test benefit information, plans
that cover a richer benefit than Original Medicare do not need to
include given description (unless still applicable) and may instead
describe plan benefit.]
Abdominal aortic aneurysm screening
A one-time screening ultrasound for people at risk. The plan only
covers this screening if you get a referral for it as a result of your
“Welcome to Medicare” physical exam.
Welcome to Medicare exam (covered during the first 12 months that the
enrollee has Medicare Part B).
The reimbursement for this benefit does not include reimbursement for
EKGs, clinical laboratory tests, as well as screening and other

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

preventative services currently covered under Medicare Part B.
[Also list any additional benefits offered.]
“Welcome to Medicare” exam
Welcome to Medicare exam (covered during the first 12 months that the
enrollee has Medicare Part B).

[List copays/
coinsurance]

The reimbursement for this benefit does not include reimbursement for
EKGs, clinical laboratory tests, as well as screening and other
preventative services currently covered under Medicare Part B.
[Also list any additional benefits offered.]
Bone mass measurement
For qualified individuals (generally, this means people at risk of
losing bone mass or at risk of osteoporosis), the following services
are covered every 2 years or more frequently if medically necessary:
procedures to identify bone mass, detect bone loss, or determine
bone quality, including a physician’s interpretation of the results.
[Also list any additional benefits offered.]

[List copays/
coinsurance]

Colorectal screening
For people 50 and older, the following are covered:

• Flexible sigmoidoscopy (or screening barium enema as an
alternative) every 48 months

• Fecal occult blood test, every 12 months
For people at high risk of colorectal cancer, we cover:

• Screening colonoscopy (or screening barium enema as an
alternative) every 24 months
For people not at high risk of colorectal cancer, we cover:

• Screening colonoscopy every 10 years, but not within 48 months
of a screening sigmoidoscopy
[Also list any additional benefits offered.]

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

Immunizations
Covered services include:

• Pneumonia vaccine
• Flu shots, once a year in the fall or winter
• Hepatitis B vaccine if you are at high or intermediate risk of

[List copays/
coinsurance]

getting Hepatitis B

• Other vaccines if you are at risk
We also cover some vaccines under our outpatient prescription drug
benefit. [Also list any additional benefits offered.]
Mammography screening
Covered services include:

• One baseline exam between the ages of 35 and 39
• One screening every 12 months for women age 40 and older

[List copays/
coinsurance]

[Also list any additional benefits offered.]
Pap test, pelvic exams, and clinical breast exams
Covered services include:

• For all women, Pap tests, pelvic exams, and clinical breast exams

[List copays/
coinsurance]

are covered once every 24 months

• If you are at high risk of cervical cancer or have had an abnormal
Pap test and are of childbearing age: one Pap test every 12
months
[Also list any additional benefits offered.]
Prostate cancer screening exams
For men age 50 and older, covered services include the following - once
every 12 months:

• Digital rectal exam
• Prostate Specific Antigen (PSA) test
[Also list any additional benefits offered.]

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or abnormalities
associated with an elevated risk of cardiovascular disease). [Insert
frequency.]

[List copays/
coinsurance]

Physician exams
[Plans that cover only what Original Medicare covers insert: A one-time
physical exam for members within the first 12 months that they have
Medicare Part B. Includes measurement of height, weight and blood
pressure; an electrocardiogram; education, counseling and referral with
respect to covered screening and preventive services. Doesn’t include lab
tests.]

[List copays/
coinsurance]

Other Services
Dialysis (kidney)
Covered services include:

• Outpatient dialysis treatments (including dialysis treatments when

[List copays/
coinsurance]

temporarily out of the service area)

• Inpatient dialysis treatments (if you are admitted to a hospital for
special care)

• Self-dialysis training (includes training for you and anyone
helping you with your home dialysis treatments)

• Home dialysis equipment and supplies
• Certain home support services (such as, when necessary, visits by
trained dialysis workers to check on your home dialysis, to help
in emergencies, and check your dialysis equipment and water
supply)
Medicare Part B prescription drugs
These drugs are covered under Part B of Original Medicare. Members of
our plan receive coverage for these drugs through our plan. Covered
drugs include:

• Drugs that usually aren’t self-administered by the patient and are

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

injected while you are getting physician services

• Drugs you take using durable medical equipment (such as
nebulizers) that was authorized by the plan

• Clotting factors you give yourself by injection if you have
hemophilia

• Immunosuppressive Drugs, if you were enrolled in Medicare Part
A at the time of the organ transplant

• Injectable osteoporosis drugs, if you are homebound, have a bone
fracture that a doctor certifies was related to post-menopausal
osteoporosis, and cannot self-administer the drug

• Antigens
• Certain oral anti-cancer drugs and anti-nausea drugs
• Certain drugs for home dialysis, including heparin, the antidote
for heparin when medically necessary, topical anesthetics, and
erythropoisis-stimulating agents (such as Epogen, Procrit,
Epoetin Alfa, Aranesp, or Darbepoetin Alfa)

• Intravenous Immune Globulin for the home treatment of primary
immune deficiency diseases
[PFFS who offer Part D coverage include: Chapter 5 explains the
Part D prescription drug benefit, including rules you must follow to
have prescriptions covered. What you pay for your Part D
prescription drugs through our plan is listed in Chapter 6].

Additional Benefits
[For all additional benefits information, plans should include only
applicable rows.]

[List copays/
coinsurance]

Dental services
[List any additional benefits offered, such as routine dental care.]
Hearing services
[List any additional benefits offered, such as routine hearing care.]

[List copays/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

Services that are covered for you

What you must
pay when you get
these services

Vision care
[List any additional benefits offered, such as routine vision exams or
glasses, unless included in “Vision Care” section earlier in benefits
chart.]

[List copays/
coinsurance]

Health and wellness education programs
[These are programs focused on clinical health conditions such as high
blood pressure, cholesterol, asthma, and special diets. Programs
designed to enrich the health and lifestyles of members include weight
management, smoking cessation, fitness, and stress management.
Describe the nature of the programs here.]
[Include other additional benefits being offered.]

Chapter 4
Section 2.2

[List copays/
coinsurance]

Extra “optional supplemental” benefit
you can buy

[Include this section if you offer optional supplemental benefits in the Plan. (You may include
this section either in the EOC or as an insert to the EOC.)]
Our Plan offers some extra benefits that are not covered by Original Medicare and not included
in your benefits package as a plan member. These extra benefits are called “Optional
Supplemental Benefits.” If you want these optional supplemental benefits, you must sign up for
them [insert if applicable: and you may have to pay an additional premium for them]. The
optional supplemental benefits included in this section are subject to the same appeals process as
any other benefits.
[Insert plan specific optional benefits, premiums, deductible, copays and coinsurance and rules
using a chart like the Benefits Chart above. Insert plan specific procedures on how to elect
optional supplemental coverage, including application process and effective dates and on how to
discontinue optional supplemental coverage, including refund of premiums. Also insert any
restrictions on members’ re-applying for optional supplemental coverage (e.g., must wait until
next annual enrollment period).]

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

SECTION 3

Chapter 4
Section 3.1

What types of benefits are not covered
by the plan?

Types of benefits we do not cover

This section tells you what kinds benefits are “excluded.” Excluded means that the plan doesn’t
cover these benefits.
The list below describes some services and items that aren’t covered under any conditions and
some that are excluded only under specific conditions.
If you get benefits that are excluded, you must pay for them yourself. We won’t pay for the
medical benefits listed in this section (or elsewhere in this booklet), and neither will Original
Medicare. The only exception: If a benefit on the exclusion list is found upon appeal to be a
medical benefit that 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 medical service, go to
Chapter 9, Section 5.3 in this booklet.)
In addition to any exclusions or limitations described in the Benefits Chart, or anywhere else in
this Evidence of Coverage, [mention any other places where exclusions are given, such as
addenda,] the following items and services aren’t covered under Original Medicare or by
our plan:
[The services listed in the remaining bullets are excluded from Original Medicare’s benefit
package. If any services below are covered supplemental benefits, delete them from this list.
When plans partially exclude services excluded by Medicare they need not delete the item
completely from the list of excluded services but may revise the text accordingly to describe the
extent of the exclusion. Plans may also indicate if a service may be covered as an optional
supplemental benefit.]
•

Services considered not reasonable and necessary, according to the standards of Original
Medicare, unless these services are listed by our plan as a covered services.

•

Experimental medical and surgical procedures, equipment and medications, unless
covered by Original Medicare. However, certain services may be covered under a
Medicare-approved clinical research study. See Chapter 3, Section 5 for more
information on clinical research studies.

•

Surgical treatment for morbid obesity, except when it is considered medically necessary
and covered under Original Medicare.

•

Private room in a hospital, except when it is considered medically necessary.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

•

Private duty nurses.

•

Personal items in your room at a hospital or a skilled nursing facility, such as a telephone
or a television.

•

Full-time nursing care in your home.

•

Custodial care, unless it is provided with covered skilled nursing care and/or skilled
rehabilitation services. Custodial care, or non-skilled care, is care that helps you with
activities of daily living, such as bathing or dressing.

•

Homemaker services provide basic household assistance, including light housekeeping or
light meal preparation.

•

Fees charged by your immediate relatives or members of your household.

•

Meals delivered to your home.

•

Elective or voluntary enhancement procedures or services (including weight loss, hair
growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and
mental performance), except when medically necessary.

•

Cosmetic surgery or procedures because of an accidental injury or to improve a
malformed part of the body. However, all stages of reconstruction are covered for a
breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical
appearance.

•

Routine dental care, such as cleanings, filings or dentures. However, non-routine dental
care received at a hospital may be covered.

•

Chiropractic care, other than manual manipulation of the spine consistent with Medicare
coverage guidelines.

•

Routine foot care, except for the limited coverage provided according to Medicare
guidelines.

•

Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of
the brace or the shoes are for a person with diabetic foot disease.

•

Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with
diabetic foot disease.

•

Hearing aids and routine hearing examinations.

•

Eyeglasses, routine eye examinations, radial keratotomy, LASIK surgery, vision therapy
and other low vision aids. However, eyeglasses are covered for people after cataract
surgery.

•

Prescription drugs for treatment of sexual dysfunction, including erectile dysfunction,
impotence, and anorgasmy or hyporgasmy.

•

Reversal of sterilization procedures, sex change operations, and non-prescription
contraceptive supplies.

2010 Evidence of Coverage for [insert plan name]
Chapter 4: Medical benefits chart (what is covered and what you pay)

•

Acupuncture.

•

Naturopath services (uses natural or alternative treatments).

•

Services provided to veterans in Veterans Affairs (VA) facilities. However, when
emergency services are received at VA hospital and the VA cost-sharing is more than the
cost-sharing under our plan. We will reimburse veterans for the difference. Members are
still responsible for our cost-sharing amounts.

•

Any services listed above that aren’t covered will remain not covered even if received at
an emergency facility.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

[PFFS without Part D coverage: Omit this chapter]

CHAPTER 5: 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. Your prescriptions should be written by a network provider
2.1

In most cases, your prescription must be from a network provider ........................ [xx]

SECTION 3. Fill your prescription at a network pharmacy or through
the plan’s mail order service
3.1

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

3.2

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

3.3

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

3.4

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

3.5

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

SECTION 4. Your drugs need to be on the Plan’s “Drug List”
4.1

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

4.2

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

4.3

How can you find out if a specific drug is on the Drug List? ................................. [xx]

SECTION 5. There are restrictions on coverage for some drugs
5.1

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

5.2

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

5.3

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

SECTION 6. What if one of your drugs is not covered in the way
you’d like it to be covered?
6.1 There are things you can do if your drug is not covered in the way you’d like it
to be covered ......................................................................................................... [xx]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

6.2 What can you do if a drug is not on the Drug List or if it is restricted in some
way? ...................................................................................................................... [xx]
6.3

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

SECTION 7. What if your coverage changes for one of your drugs?
7.1

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

7.2

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

SECTION 8. What types of drugs are not covered by the plan?
8.1

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

SECTION 9. Show your plan membership card when you fill a prescription
9.1

Show your membership card ................................................................................ [xx]

9.2

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

SECTION 10. Part D drug coverage in special situations
10.1

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

10.2

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

10.3

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

SECTION 11. Programs on drug safety and managing medications
11.1

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

11.2

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

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

Did you know there are programs to help
people pay for their drugs?
There are programs to help people with limited resources pay for their drugs.
These include “Extra Help” and state pharmaceutical assistance programs. For
more information, see Chapter 1, 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 5
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 6, What you pay for your Part D prescription drugs).
In addition to your coverage for Part D drugs, [insert plan name] also covers some drugs under
the plan’s medical benefits:
•

The plan covers drugs you are given during covered stays in the hospital or in a
skilled nursing facility. Chapter 4 (Medical benefits chart, what is covered and what
you pay), tells about the benefits and costs for drugs during a covered hospital or skilled
nursing facility stay.

•

The plan also provides benefits for drugs covered under Medicare Part B. 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. Chapter 4 tells about your benefits and costs
for Part B drugs.

The two types of drugs described above are covered by the plan’s medical benefits. The rest of
your prescription drugs are covered under the plan’s Part D benefits. This chapter explains

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

rules for using your coverage for Part D drugs. The next chapter tells what you pay for Part D
drugs (Chapter 6, What you pay for your Part D prescription drugs).

Chapter 5
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:
•

[Omit if not applicable: You must have a network provider write your prescription. (For
more information, see Section 2, Your prescriptions should be written by a network
provider.)]

•

You must use a network pharmacy to fill your prescription. (See Section 3, 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 4, 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

Your prescriptions should be written by
a network provider

[Plans should omit this section if not applicable.]
Chapter 5
Section 2.1

In most cases, your prescription must be
from a network provider

You need to get your prescription (as well as your other care) from a provider in the plan’s
provider network. This person would often be your primary care provider (your PCP). It could
also be another professional in our provider network if your PCP has referred you for care.
To find network providers, look in the Provider Directory.
The plan will cover prescriptions from providers who are not in the plan’s network only in
a few special circumstances. These include:
•

Prescriptions you get in connection with emergency care.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

•

Dialysis you get when you are traveling outside of the plan’s service area.

Other than these circumstances, you must have approval in advance (“prior authorization”) from
the plan to get coverage of a prescription from an out-of-network provider.
If you pay “out-of-pocket” for a prescription written by an out-of-network provider and you
think we should cover this expense, please contact Member Services or send the bill to us for
payment. Chapter 7, Section 2.1 tells how to ask us to pay our share of the cost.

SECTION 3

Chapter 5
Section 3.1

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
drugs. [Describe restrictions imposed on members that use non-preferred pharmacies.]]
Chapter 5
Section 3.2

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.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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 specialty pharmacy?
Sometimes prescriptions must be filled at a specialty pharmacy. Specialty 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 specialty pharmacy, look in your Pharmacy Directory or call Member Services.
Chapter 5
Section 3.3

Using the plan’s mail-order services

[Omit 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.)]

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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 5
Section 3.4

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
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 of [insert either:
maintenance OR mail order] drugs. Some of these retail pharmacies [insert if applicable:
may] agree to accept the mail-order cost-sharing amount for an extended supply of [insert
either: maintenance OR mail order] drugs, which may result in no out-of-pocket
difference to you. [Insert if applicable: Other retail pharmacies may not agree to accept
the 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.
2. 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 5
Section 3.5

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

Your prescription might be covered in certain situations

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

Generally, we cover drugs filled at an out-of-network 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 7, Section 2.1 explains how to ask the plan to
pay you back.)

SECTION 4

Chapter 5
Section 4.1

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.
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.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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 5
Section 4.2

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 6 (What you pay for your
Part D prescription drugs).

Chapter 5
Section 4.3

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.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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 5

Chapter 5
Section 5.1

There are restrictions on coverage for
some drugs

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 to use that lower-cost option. We
also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

Chapter 5
Section 5.2

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.)

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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.
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 5
Section 5.3

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]).

SECTION 6

Chapter 5
Section 6.1

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

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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 5, some of the drugs covered by the plan have extra
rules to restrict their use. For example, 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. 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 four 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. 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 6.2 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 6.3 to learn what you
can do.

Chapter 5
Section 6.2

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 may be able to get a temporary supply of their drug (only members in certain
situations can get a temporary supply).
You can change to another drug.
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
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.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

To be eligible for a temporary supply, you must meet the two requirements given 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 5 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)],
or less if your prescription is written for fewer days.

•

For those who are new members, and aren’t 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.
[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 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

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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. 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 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 provider says that you have medical
reasons that justify asking us for an exception, your provider 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.
[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 want to ask for an exception, Chapter 9, Section 6.2 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 5
Section 6.3

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 may 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. 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 to find a covered drug that
might work for you.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

You can file an exception
You and your doctor 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 provider says that you have medical reasons
that justify asking us for an exception, your doctor can help you request an exception to the rule.
If you and your doctor want to ask for an exception, Chapter 9, Section 6.2 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.

SECTION 7

Chapter 5
Section 7.1

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.

•

[Insert if applicable: 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 5 in this chapter).

•

Replace a brand-name drug with a generic drug.

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

Chapter 5
Section 7.2

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

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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?
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, may omit: 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 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 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 9 (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 will also know about this change, and can work with you to
find another drug for your condition.

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

SECTION 8

Chapter 5
Section 8.1

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, Section 6.5 in this booklet.)
Here are three 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 5: Using the plan’s coverage for your Part D prescription drugs

•

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 6, 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 9

Chapter 5
Section 9.1

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

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 5
Section 9.2

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 7, Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 10

Chapter 5
Section 10.1

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 the plan?

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we
will generally cover the cost of your prescription drugs during your stay. Once you leave the
hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of
our rules for coverage. See the previous parts of this section that tell about the rules for getting
drug coverage. Chapter 6 (What you pay for your Part D prescription drugs) gives more
information about drug coverage and what you pay.
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 10, Ending your membership in the
plan, tells you can leave our plan and join a different Medicare plan.)

Chapter 5
Section 10.2

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

2010 Evidence of Coverage for [insert plan name]
Chapter 5: Using the plan’s coverage for your Part D prescription drugs

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 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 9, Section 6.2 tells what to
do.

Chapter 5
Section 10.3

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

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 11

Chapter 5
Section 11.1

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

Chapter 5
Section 11.2

Programs to help members manage their
medications

[Plans should include this section only if applicable.]
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 6: What you pay for your Part D prescription drugs

[PFFS without Part D coverage: Omit this chapter]

CHAPTER 6: 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]

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

6.2

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

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 6: What you pay for your Part D prescription drugs

Did you know there are programs to help people pay for
their drugs?
There are programs to help people with limited resources pay for their
drugs. These include “Extra Help” and state pharmaceutical assistance
programs. 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 6
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 5,
Section 8.1, 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.
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.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

•

Chapter 5 of this booklet. Chapter 5 gives the details about your prescription drug
coverage, including rules you need to follow when you get your covered drugs. Chapter 5
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 5 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 6
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.
[Plans with no deductible and/or no coverage gap, should revise the chart as needed to
describe their drug coverage stages.]
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 spend for your drugs while you are in each
stage.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

Stage 1

Stage 2

Stage 3

Stage 4

Yearly Deductible
Stage

Initial Coverage
Stage

Coverage Gap
Stage

Catastrophic
Coverage Stage

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.

[Insert either:

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].

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.

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.)

You pay the full
cost of your
drugs.
OR The plan will
provide limited
coverage during
the coverage gap
stage.]
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.)

(Details are in
Section [insert as
appropriate: 6 OR
7] of this chapter.)

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

SECTION 3

Chapter 6
Section 3.1

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 report gives the payment details about the
prescriptions you have filled during the month. It shows the total drug 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 6
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
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

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

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 purchase a drug at a price that is better than you can get under our plan.
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.
•

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 6
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 6: What you pay for your Part D prescription drugs

•

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 6
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:
•

A retail pharmacy that is in our plan’s network

•

The plan’s mail-order pharmacy

•

A pharmacy that is not in the plan’s network

For more information about these pharmacy choices and filling your prescriptions, see Chapter 5
in this booklet and the plan’s Pharmacy Directory.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

Chapter 6
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.]
Your share of the cost when you get a 30-day supply (or less) of a covered Part D
prescription drug from:

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

Cost Group 2
([insert
description])

Cost Group 3
([insert
description])

Cost Group 4
([insert
description])

Network
pharmacy

The plan’s
mail-order
serviceservice

Network longterm care
pharmacy

[Insert copay/
coinsurance]

Out-of-network
Pharmacy
(coverage is
limited to
certain
situations, see
Chapter 5 for
details)
[Insert copay/
coinsurance]

[Insert copay/
coinsurance]

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

Chapter 6
Section 5.3

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.]
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 6
Section 5.4

Network pharmacy

The plan’s mail-order service
der service

[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:

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

• 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.
• 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 6
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,

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

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.]]
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 6
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 6: What you pay for your Part D prescription drugs

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.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

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.
• 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,

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

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

Chapter 6
Section 7.1

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

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.]

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

SECTION 8

Chapter 6
Section 8.1

Additional benefits information

Our plan offers additional benefits

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

SECTION 9

Chapter 6
Section 9.1

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

Our plan has separate 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 medical benefits. You can find out about your
coverage of these vaccines by going to Chapter 4, Medical benefits chart (what is
covered and what you pay).
o Other 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.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

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

You buy the vaccine at the pharmacy and you get your vaccination shot at the
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: coinsurance OR copayment OR coinsurance or
copayment] for the vaccine itself.
• Our plan will pay for the cost of giving you the vaccination shot.

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 7 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 OR 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 receive extra help, 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 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

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

•

100

of the cost by using the procedures described in Chapter 7 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.]

Chapter 6
Section 9.2

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 6
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.

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

101

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 6
Section 10.2

How much is the Part D late enrollment
penalty?

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

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 6
Section 10.3

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

2010 Evidence of Coverage for [insert plan name]
Chapter 6: What you pay for your Part D prescription drugs

102

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.

•

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 6
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 7: Asking the plan to pay its share of a bill you have received for covered services or drugs 103

CHAPTER 7: Asking the plan to pay its share of a bill you have received
for covered services or drugs

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

If you pay our plan’s share of the cost of your covered services or if you
receive a bill, you can ask us for payment ............................................................ [xx]

SECTION 2. How to ask our plan to pay you back or to pay a bill you have
received
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 pay you back and how much we owe........... [xx]

3.2

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

2010 Evidence of Coverage for [insert plan name]
Chapter 7: Asking the plan to pay its share of a bill you have received for covered services or drugs 104

SECTION 1

Chapter 7
Section 1.1

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

If you pay our plan’s share of the cost or if
you receive a bill for your covered
services, you can ask us for payment

Sometimes when you get medical care or [if applicable: 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). It is your right to be paid back by our
plan whenever you’ve paid more than your share of the cost for medical services or drugs that
are covered by our plan.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received. In many cases, you should send this bill to us instead of paying it. We will
look at the bill and decide whether the services should be covered. If we decide they should be
covered, we will pay the provider directly.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay
a bill you have received:
1. When you’ve received emergency care from a provider who is not in
our plan’s network
You can receive emergency services from any provider, whether or not the provider is a part
of our network. When you receive emergency care from a provider who is not part of our
network, you are only responsible for paying your share of the cost, not for the entire cost.
You should ask the provider to bill the plan for our share of the cost.
•

If you pay the entire amount yourself at the time you receive the care, you need to ask
us to pay you back for our share of the cost. Send us the bill, along with documentation
of any payments you have made.

•

At times you may get a bill from the provider asking for payment that you think you do
not owe. Send us this bill, along with documentation of any payments you have already
made.
o If the provider is owed anything, we will pay the provider directly.
o If you have already paid more than your share of the cost of the service, we will
determine how much you owed and pay you back for our share of the cost.

2010 Evidence of Coverage for [insert plan name]
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2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly, and ask you only for your share of
the cost. But sometimes they make mistakes, and ask you to pay more than your share.
•

Whenever you get a bill from a network provider that you think is more than you
should pay, send us the bill. We will contact the provider directly and resolve the
billing problem.

•

If you have already paid a bill to a network provider, but you feel that you paid too
much, send us the bill along with documentation of any payment you have made and
ask us to pay you back.

3. 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.

4. 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.
•

Save your receipt and send a copy to us when you ask us to pay you back.

5. 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.
•

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.

[Plans should insert additional circumstances under which they will accept a paper claim
from an enrollee.]

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How to ask us to pay you back or to pay
a bill you have received

SECTION 2

Chapter 7
Section 2.1

How and where to send us your request
for payment

Send us your request for payment, along with your bill and documentation of any payment you
have made. It’s a good idea to make a copy of your bill and 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.

•

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 bills or 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, or you receive bills and you don’t know what to do about those bills, 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 7
Section 3.1

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

We check to see whether we should cover
the service or 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.

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•

If we decide that the medical care or drug is covered and you followed all the rules for
getting the care or drug, we will pay for our share of the cost. If you have already paid for
the service or drug, we will mail your reimbursement to you. If you have not paid for the
service or drug yet, we will mail the payment directly to the provider. (Chapter 3 explains
the rules you need to follow for getting your medical services. Chapter 5 explains the rules
you need to follow for getting your Part D prescription drugs.)

•

If we decide that the medical care or 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.

Chapter 7
Section 3.2

If we tell you that we will not pay for the
medical care or 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.
For the details on how to make this appeal, go to Chapter 9 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 complicated 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 9. 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 in Chapter 9 that tells what to do for your situation:
•

If you want to make an appeal about getting paid back for a medical service, go to
Section 5.4 in Chapter 9.

•

If you want to make an appeal about getting paid back for a drug, go to Section 6.6 of
Chapter 9.

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CHAPTER 8: 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, 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 services [insert
if applicable: and 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 providers, 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]
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SECTION 1

Chapter 8
Section 1.1

109

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, in large print, or other
alternate formats, etc.)

[Note: Plans may include NCQA-required language if when necessary.]
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 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 8
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.

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Chapter 8
Section 1.3

110

We must ensure that you get timely
access to your covered services [insert if
applicable: and drugs]

You may seek care from any provider in the United States who is eligible to be paid by Medicare
and agrees to accept our plan’s terms and conditions of payment. You should always (except
possibly in emergencies) show the provider your PFFS plan membership card. If the provider
treats you, the provider becomes a “deemed provider”, meaning that the provider is now bound
to abide by our rules even if the provider did not read our terms and conditions of payment. As a
plan member, you have the right to get appointments and covered services from the plan’s
network of providers within a reasonable amount of time.

Chapter 8
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.

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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 8
Section 1.5

We must give you information about the
plan, its network of providers, and your
covered services

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
Advantage health plans.

•

Information about our network providers [insert if applicable: including our
network pharmacies].
o For example, you have the right to get information from us about the
qualifications of the providers [insert if applicable: and pharmacies] in our
network and how we pay the providers in our network.
o For a list of the providers in the plan’s network, see the [insert name of provider
directory].
o [Insert if applicable: For a list of the pharmacies in the plan’s network, see the
[insert name of pharmacy directory].]

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o For more detailed information about our providers [insert if applicable: or
pharmacies], you can call Member Services (phone numbers are on the cover of
this booklet) or visit our website at [insert URL].
•

Information about your coverage and rules you must follow in using your
coverage.
o In Chapters 3 and 4 of this booklet, we explain what medical services are covered
for you, any restrictions to your coverage, and what rules you must follow to get
your covered medical services.
o [Insert if applicable: To get the details on your Part D prescription drug coverage,
see Chapters 5 and 6 of this booklet plus the plan’s [insert name of formulary].
These chapters, together with the [insert name of formulary], 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 medical service [insert if applicable: or 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
medical service [insert if applicable: or drug] from an out-of-network provider
[insert if applicable: or pharmacy].
o If you are not happy or if you disagree partially or fully with a decision we make
about what medical care [insert if applicable: or 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 9 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 9 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 a bill you have received for
medical care [insert if applicable: or a Part D prescription drug], see Chapter 7 of
this booklet.

Chapter 8
Section 1.6

We must support your right to make
decisions about your care

You have the right to know your treatment options and
participate in decisions about your health care

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You have the right to get full information from your doctors and other health care providers
when you go for medical care. Your providers must explain your medical condition and your
treatment choices in a way that you can understand.
You also have the right to participate fully in decisions about your health care. To help you make
decisions with your doctors about what treatment is best for you, your rights include the
following:
•

To know about all of your choices. This means that you have the right to be told about
all of the treatment options that are recommended for your condition, no matter what they
cost or whether they are covered by our plan. [Insert if applicable: It also includes being
told about programs our plan offers to help members manage their medications and use
drugs safely.]

•

To know about the risks. You have the right to be told about any risks involved in your
care. You must be told in advance if any proposed medical care or treatment is part of a
research experiment. You always have the choice to refuse any experimental treatments.

•

The right to say “no.” You have the right to refuse any recommended treatment. This
includes the right to leave a hospital or other medical facility, even if your doctor advises
you not to leave. You also have the right to stop taking your medication. Of course, if you
refuse treatment or stop taking medication, you accept full responsibility for what
happens to your body as a result.

•

To receive an explanation if you are denied care. You have the right to receive an
explanation from us if a provider has denied care that you believe you should receive. To
receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of this
booklet tells how to ask the plan for a coverage decision.

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
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:

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•

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 8
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 9 of this
booklet tells what you can do. It gives the details about how to deal with all types of problems
and complaints.
As explained in Chapter 9, 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.

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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 8
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 Federal government’s Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800537-7697, 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 8
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 contact the Medicare.
o You can visit http://www.medicare.gov/Publications/Pubs/pdf/10112.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.

2010 Evidence of Coverage for [insert plan name]
Chapter 8: Your rights and responsibilities

SECTION 2

Chapter 8
Section 2.1

116

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 services and the rules you must follow to
get these covered services. Use this Evidence of Coverage booklet to learn what
is covered for you and the rules you need to follow to get your covered services.
o Chapters 3 and 4 give the details about your medical services, including what is
covered, what is not covered, rules to follow, and what you pay.
o [Insert if applicable: Chapters 5 and 6 give the details about your coverage for
Part D prescription drugs.]

•

If you have any other health insurance coverage [insert if applicable: or
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 services from
our plan. This is called “coordination of benefits” because it involves
coordinating the health [insert if applicable: and drug] benefits you get from our
plan with any other health [insert if applicable: and drug] benefits available to
you. We’ll help you with it.

•

Tell your doctor and other health care providers that you are enrolled in our
plan. Show your plan membership card whenever you get your medical care [insert if
applicable: or 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.

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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.
•

Be considerate. We expect all our members to respect the rights of other patients.
We also expect you to act in a way that helps the smooth running of your doctor’s
office, hospitals, and other offices.

•

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 medical services [insert if applicable: or drugs] covered by the
plan, you must pay your share of the cost when you get the service [insert if
applicable: or drug]. This will be a [insert as appropriate: copayment (a fixed
amount) OR coinsurance (a percentage of the total cost) OR copayment (a fixed
amount) or coinsurance (a percentage of the total cost)]. Chapter 4 of this booklet
tells what you must pay for your medical services. [Insert if applicable: Chapter 6
tells what you must pay for your Part D prescription drugs.]
o If you get any medical services or 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 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.

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CHAPTER 9: 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 medical care: How to ask for a coverage decision or
make an appeal
5.1

This section tells what to if you have problems getting medical care or you
want us to pay you back for our share of the cost of your care ............................. [xx]

5.2

Step-by-step: How to ask for a coverage decision (how to ask our plan to
provide the medical care coverage you want) ...................................................... [xx]

5.3

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

5.4

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

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5.5

What if you are asking our plan to pay you for our share of a bill you
have received for medical care? ........................................................................... [xx]

SECTION 6. Your Part D prescription drugs: How to ask for a
coverage decision or make an appeal
6.1

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]

6.2

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

6.3

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

6.4

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

6.5

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]

6.6

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

6.7

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 7. How to ask for a longer hospital stay if you think you
are being asked to leave the hospital too soon
7.1

During your hospital stay, you will get a written notice from Medicare that
tells about your rights .......................................................................................... [xx]

7.2

Step-by-step: How to make a Level 1 Appeal to change your hospital
discharge date...................................................................................................... [xx]

7.3

Step-by-step: How to make a Level 2 Appeal to change your hospital
discharge date...................................................................................................... [xx]

7.4

What if you miss the deadline for making your Level 1 appeal? .......................... [xx]

SECTION 8. How to ask our plan to keep covering a medical service you have
been getting if you think your coverage is ending too soon
8.1

This section is about three services only: Home health care, skilled
nursing facility care, and Comprehensive Outpatient Rehabilitation
Facility (CORF) services ..................................................................................... [xx]

8.2

We will tell you in advance when your coverage will be ending .......................... [xx]

8.3

Step-by-step: How to make a Level 1 Appeal to have our plan cover
your care for a longer time................................................................................... [xx]

8.4

Step-by-step: How to make a Level 2 Appeal to have our plan cover
your care for a longer time................................................................................... [xx]

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8.5

What if you miss the deadline for making your Level 1 appeal? .......................... [xx]

SECTION 9.
9.1

Taking your appeal to Level 3 and beyond

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

Making complaints
SECTION 10. How to make complaints about quality of care, waiting
times, customer service, or other concerns
10.1

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

10.2

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

10.3

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

10.4

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

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Background

SECTION 1

Chapter 9
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.

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Chapter 9
Section 1.2

What about the legal terms?

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 “organization
determination” or “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 9
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.

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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
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 (http://www.medicare.gov).

SECTION 3

Chapter 9
Section 3.1

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

Should you use the process for coverage
decisions and appeals? Or should you use
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.

Coverage decisions and appeals

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The process for coverage decisions and making appeals deals with problems related to your
benefits and coverage for medical services and prescription drugs, including problems related
to payment. This is the process you use for issues such as whether something is covered or not
and the way in which something is covered.
[MA-only plans: revise language to omit references to drugs.]
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 medical services or drugs. You ask us for a coverage decision
whenever you go to a doctor for medical care. You can also contact the plan and ask for a
coverage decision. For example, if you want to know if we will cover a medical service before
you receive it.
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 service is covered and pay our share of the
cost

•

But in some cases we might decide the services are not covered for you. Or we may
decide it is time to stop covering services you have been receiving. If you disagree with
this coverage decision, you can make an appeal.

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

Chapter 9
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 involved. In most situations involving
a coverage decision or appeal, your doctor must explain the medical reasons that support
your request.

•

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.
o There may be someone who is already legally authorized to act as your
representative under State law.
o If you want a friend, relative, your doctor, 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.

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However, you are not required to hire a lawyer to ask for any kind of coverage
decision or appeal a decision.

Chapter 9
Section 4.3

Which section of this chapter gives the
details for your situation?

[For PFFS without Part D coverage, plans should modify the graphic to remove Part D related
coverage decisions and appeals.]
There are four different types of situations that involve coverage decisions and appeals. Since
each situation has different rules and deadlines, we give the details for each one in a separate
section:

If you’re still not sure which section you should be using, please call Member Services (phone
numbers are on the front cover). You can also get help or information from government
organizations such as your State Health Insurance Assistance Program (Chapter 2, Section 3,
of this booklet has the phone numbers for this program).

SECTION 5

Your medical care: How to ask for a
coverage decision or make an appeal

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.

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Chapter 9
Section 5.1

This section tells what to if you have
problems getting medical care or if you want
us to pay you back for medical care

This section is about your benefits for medical care and services. These are the benefits described
in Chapter 4 of this booklet: Medical benefits chart (what is covered and what you pay). To keep
things simple, we generally refer to “medical care coverage” or “medical care” in the rest of this
section, instead of repeating “medical care or treatment or services” every time.
This section tells what you can do if you are in any of the five following situations:
1. You are not getting certain medical care you want, and you believe that this care is
covered by our plan.
2. Our plan will not approve the medical care your doctor or other medical provider wants to
give you, and you believe that this care is covered by the plan.
3. You have received medical care or services that you believe should be covered by the plan,
but we have said we will not pay for this care.
4. You have received and paid for medical care or services that you believe should be covered
by the plan, and you want to ask our plan to reimburse you for this care.
5. You are being told that certain medical care you have been getting will be reduced or
stopped, and you believe that reducing or stopping this care could harm your health.
•

NOTE: If the care that will be stopped is hospital care, home health care,
skilled nursing facility care, or Comprehensive Outpatient Rehabilitation
Facility (CORF) services, you need to read a separate section of this chapter
because special rules apply to these types of care. Here’s what to read in those
situations:
o Chapter 9, Section 7: How to ask for a longer hospital stay if you think you are
being asked to leave the hospital too soon.
o Chapter 9, Section 8: How to ask our plan to keep covering a medical service
you have been getting if you think your coverage is ending too soon. This
section is about three services only: home health care, skilled nursing facility
care, and Comprehensive Outpatient Rehabilitation Facility (CORF) care.

•

For all other situations that involve being told that medical care you have been getting
will be stopped, use this section (Section 5) as your guide for what to do. (Section 5
does not apply to Part D drugs, see Section 6 for information on Part D drug appeals.)

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Chapter 9
Section 5.2

Step-by-step how to ask for a
coverage decision
(how to ask our plan to provide the
medical care coverage you want)
A coverage decision is called an “initial
determination” or “initial decision.” When
a coverage decision involves your medical
care, the initial determination is called an
“organization determination.”

Step 1 

You ask our plan to make a coverage decision on the
medical care you are requesting. If your health requires a
quick response, you must ask us to make a “fast decision.”
A “fast decision” is called an “expedited
decision.”

How to request coverage for the medical care you want
•

Start by [insert if applicable: calling,] writing, or faxing our plan to make your
request for us to authorize or provide coverage for the medical care you want. You,
or your doctor, or your representative can do this.

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•

For the details on how to contact us, including how to reach us on evenings and
weekends, go to Chapter 2, Section 1.2 and look for the section called, How to
reach our plan when you are asking for a coverage decision about your medical
care.

Generally we use the standard deadlines for giving you our 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
14 days after we receive your request.
•

However, we can take up to 14 more days if you ask for more time, or if we need
information (such as medical records) that may benefit you. If we decide to take extra
days to make the decision, we will tell you in writing.

•

If you believe we should not take extra days, you can file a “fast complaint” about
our decision to take extra days. When you file a fast complaint, we will give you
an 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, including fast complaints, see Section 10 of
this chapter.)

If your health requires it, ask us to give you a “fast decision”
•

A fast decision means we will answer within 72 hours.
o However, we can take up to 14 more days if we find that some information
is missing that may benefit you, or if you need more time to prepare for this
review. If we decide to take extra days, we will tell you in writing.
o If you believe we should not take extra days, you can file a “fast complaint”
about our decision to take extra days. (For more about the process for making
complaints, including fast complaints, see Section 10 of this chapter.) We
will call you as soon as we make the decision.

•

To get a fast decision, you must meet two requirements:
o You can get a fast decision only if you are asking for medical care you have
not yet received. (You cannot get a fast decision if your request is about
medical care you have already received.)
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 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’s support, our plan
will decide whether your health requires that we give you a fast decision.

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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 asks for the fast decision, we will
automatically give a fast decision.
o The letter will also tell how you can file a “fast complaint” about our decision
to give you a standard decision instead of the fast decision you requested. (For
more about the process for making complaints, including fast complaints, see
Section 10 of this chapter.)
Step 2 

•

Our plan considers your request for medical care
coverage and we give you our answer.

Generally, for a fast decision, we will give you our answer within 72 hours.
o As explained above, we can take up to 14 more days under certain
circumstances. If we take extra days, it is called “an extended time period.”
o If we do not give you our answer within 72 hours (or if there is an extended
time period, by the end of that period), you have the right to appeal. Section 5.3
below tells how to make an appeal.

•

If our answer is yes to part or all of what you requested, we must provide the
medical care coverage we have agreed to provide within 72 hours after we received
your request. If we extended the time needed to make our decision, we will provide
the coverage by the end of that extended period.

•

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.

•

Generally, for a standard decision, we will give you our answer within 14 days of
receiving your request.
o We can extend the time up to 14 more days (“an extended time period”) under
certain circumstances.
o If we do not give you our answer within 14 days (or if there is an extended time
period, by the end of that period), you have the right to appeal. Section 5.3
below tells how to make an appeal.

•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 14 days. If we extended the time needed

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to make our decision, we will provide the coverage by the end of that extended
period.
•

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 coverage for medical care,
you decide if you want to make an appeal

•

If our plan says no, you have the right to ask us to reconsider – and perhaps change –
this decision by making an appeal. Making an appeal means making another try to get
the medical care coverage you want.

•

If you decide to make appeal, it means you are going on to Level 1 of the appeals
process (see Section 5.3 below).

Chapter 9
Section 5.3

Step-by-step: How to make a
Level 1 Appeal
(how to ask for a review of a medical care
coverage decision made by our plan)
When you start the appeal 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 medical care
coverage decision is called a plan
“reconsideration.”

Step 1 

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

What to do

• To start your appeal, you (or your doctor or your representative) must
contact our plan. For details on how to reach us for any purpose related to your
appeal, go to Chapter 2, Section 1.2 look for section called, How to reach our plan
when you are making an appeal about your medical care.
•

Make your appeal in writing by submitting a signed request. [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 1.2 (How to reach
our plan when you are making an appeal about your medical care).]

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•

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 if you like.
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 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 care 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. (These instructions are given earlier in Section 5.2).

Step 2 

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

•

When our plan is reviewing your appeal, we take another careful look at all of the
information about your request for coverage of medical care. We check to see if we
were being fair and following all the rules when we said no to your request.

•

We will gather more information if we need it. We may contact you or your doctor to
get more information.

•

When 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 us to do so.
o However, if you ask for more time, or if we need to gather more information
that may benefit you, we can take up to 14 more days.

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o If we do not give you an answer within 72 hours (or by the end of the extended
time period if we took extra days), we are required to send your request on to
Level 2 of the appeals process, where it will be reviewed by an independent
organization. Later in this section, we tell about this organization and explain
what happens at 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.

•

If we are using the standard deadlines, we must give you our answer within 30
calendar days after we receive your appeal. We will give you our decision sooner if
your health condition requires us to.
o However, if you ask for more time, or if we need to gather more information
that may benefit you, we can take up to 14 more days.
o If we do not give you an answer within 30 days (or by the end of the extended
time period if we took extra 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 within 30 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.

Step 3 

•

If our plan says no to your appeal, your
case will automatically be sent on to the
next level of the appeals process.

To make sure we were being fair when we said no to your appeal, our plan is required
to send your appeal to the “Independent Review Organization.” When we do this, it
means that your appeal is going on to the next level of the appeals process, which is
Level 2.

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Chapter 9
Section 5.4

Step-by-step: How to make a
Level 2 Appeal

If our plan says no to your level 1 appeal, your case will automatically be sent on to the next
level of the appeals process. During the 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 

The Independent Review Organization reviews
your appeal

•

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. (For
more information about this organization, go to Chapter 2 and look for Section 5.)

•

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.]

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal.

•

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.

•

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•

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

Step 2 

The Independent Review Organization
gives you their answer

The Independent Review Organization will tell you its decision in writing and explain the
reasons for it.
•

If the review organization says yes to part or all of what you requested, we must
provide the medical care coverage that was approved by the review organization within
72 hours after we receive the decision from the review organization.

•

If this organization says no to your appeal, it means they agree with our plan that your
request for coverage for medical care 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 medical care 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.
Step 3 

If your case meets the requirements, 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 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.

•

Appeal Level 3 is handled by a judge. Section 9 in this chapter tells more about Levels 3,
4, and 5 of the appeals process.

Chapter 9
Section 5.5

What if you are asking our plan to pay you
for our share of a bill you have received
for medical care?

If you want to ask our plan for payment for medical care, start by reading Chapter 7 of this
booklet: Asking the plan to pay its share of a bill you have received for medical services or

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drugs. Chapter 7 describes the situations in which you may need to ask for reimbursement or to
pay a bill you have received from a provider. It also tells how to send us the paperwork that asks
us for payment.
Asking for reimbursement is asking for a coverage decision from our plan
If you send us the paperwork that asks for reimbursement, you are asking us to make a coverage
decision (for more about coverage decisions, see Section 4.1 of this chapter). To make this
coverage decision, we will check to see if the medical care you paid for is a covered service (see
Chapter 4: Medical benefits chart (what is covered and what you pay)). We will also check to
see if you followed all the rules for using your coverage for medical care (these rules are given
in Chapter 3 of this booklet: Using the plan’s coverage for your medical services).
We will say yes or no to your request
•

If the medical care you paid for is covered and you followed all the rules, we will send
you the payment for our share of the cost of your medical care. Or, if you haven’t paid for
the services, we will send the payment directly to the provider. When we send the
payment, it’s the same as saying yes to your request for a coverage decision.)

•

If the medical care is not covered, or you did not follow all the rules, we will not send
payment. Instead, we will send you a letter that says we will not pay for the services and
the reasons why. (When we turn down your request for payment, it’s the same as saying
no to your request for a coverage decision.)

What if you ask for payment and we say that we will not pay?
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 payment.
To make this appeal, follow the process for appeals that we describe in part 5.3 of this
section. Go to this part 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 asking us to pay you back for medical care you have
already received and paid for yourself, 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
send the payment you have requested. We are required to send payment to you or to the
provider within 30 days.

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SECTION 6

Your Part D prescription drugs: How to ask
for an exception or make an appeal

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.

[PFFS without Part D coverage: omit Section 6.]

Chapter 9
Section 6.1

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 provider 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 5 (Using our plan’s coverage
for your Part D prescription drugs) and Chapter 6 (What you pay for your Part D
prescription drugs).

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Chapter 9
Section 6.2

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 will need to
explain the medical reasons. We will then consider your request. You or your doctor 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.)

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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 drugs in Cost Group 2. You cannot
ask for an exception to the copayment or co-insurance 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 5.)

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 thinks you need the brand-name version and we agree to cover it, your
share of the cost may be greater than it would be for the generic.

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 5 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 rior 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.

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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 cannot ask for a change to the Cost Group for that drug.

Chapter 9
Section 6.3

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

Who can ask for an exception?
You or your doctor 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 must tell us the medical reasons
Your doctor 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 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.

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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 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 6.4 tells how to ask for an exception and 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 9
Section 6.4

Step-by-step: How to ask for an exception
(how to ask our plan to make an exception
for you)
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, or your doctor, or
your representative can do this (see Section 6.2 above). For the details, including
how to reach us on evenings and weekends, go to Chapter 2, Section 1.2 and look
for the section called, 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 must give us the medical reasons
for the drug exception you are requesting. (We call this the “doctor’s statement.”)

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Your doctor can fax or mail the statement to our plan. Or your doctor 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’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.)
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 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’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 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 10 of this chapter.)

Step 2 

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

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•

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’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’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.

•

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’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 9
Section 6.5

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

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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 

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

What to do
•

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 1.2, and look for
the section called, How to reach our plan when you are making an appeal
about your Part D prescription drugs.

•

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 may give us additional information to
support your appeal.

If your health requires it, ask for a “fast appeal”

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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 6.4 of this chapter.

Step 2 

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

•

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.

•

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.

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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.

Step 3 

If we say no to your appeal, you decide if
you want to continue with the appeals
process and make another 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 make another appeal, it means your appeal is going on to Level 2 of
the appeals process (see below).

Chapter 9
Section 6.6

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.

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•

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.

•

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.

What if the review organization says no to your appeal?
If this organization says no to your appeal, it means they agree with our plan that your request
for a drug coverage exception should not be approved. (This is called “upholding the decision.”
It is also called “turning down your appeal.”)

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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.

Step 3 

If your case meets the requirements, 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).

•

Appeal Level 3 is handled by a judge. Section 9 in this chapter tells more about Levels 3,
4, and 5 of the appeals process.

Chapter 9
Section 6.7

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 7 of this booklet:
Asking the plan to pay its share of a bill you have received for medical services or drugs.
Chapter 7 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 asking us to make a coverage
decision (for more about coverage decisions, see Section 4.2 of this chapter). 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.)

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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 6.)
•

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.
(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 6.5 of this
chapter. See Section 6.5 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.

SECTION 7

How to ask for a longer hospital stay if
you think you are being asked to leave
the hospital too soon

When you are admitted to a hospital, you have the right to get all of your covered hospital
services that are necessary to diagnose and treat your illness or injury. For more information
about the plan’s coverage for your hospital care, including any limitations on this coverage, see
Chapter 4 of this booklet: Medical benefits chart (what is covered and what you pay).

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During your hospital stay, your doctor and the hospital staff will be working with you to prepare
for the day when you will leave the hospital. They will also help arrange for care you may need
after you leave.
•

The day you leave the hospital is called your “discharge date.” Our plan’s coverage of
your hospital stay ends on this date.

•

When your discharge date has been decided, your doctor or the hospital staff will let you
know.

•

If you think you are being asked to leave the hospital too soon, you can ask for a longer
hospital stay and your request will be considered. This section tells you how to ask.

Chapter 9
Section 7.1

During your hospital stay, you will get a
written notice from Medicare that tells
about your rights

During your hospital stay, you will be given a written notice called An Important Message from
Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they
are admitted to a hospital. Someone at the hospital is supposed to give it to you within two days
after you are admitted.
1. Read this notice carefully and ask questions if you don’t understand it. It tells you
about your rights as a hospital patient, including:
•

Your right to receive Medicare-covered services during and after your hospital stay,
as ordered by your doctor. This includes the right to know what these services are,
who will pay for them, and where you can get them.

•

Your right to be involved in any decisions about your hospital stay, and know who
will pay for it.

•

Where to report any concerns you have about quality of your hospital care.

•

What to do if you think you are being discharged from the hospital too soon.
The written notice from Medicare tells you how you can
“make an appeal.” Making an appeal is a formal, legal way
to ask for a delay in your discharge date so that your hospital
care will be covered for a longer time. (Section 7.2 below
tells how to make this appeal.)

2. You must sign the written notice to show that you received it and understand your
rights.
•

You or someone who is acting on your behalf must sign the notice. (Section 4 of this
chapter tells how you can give written permission to someone else to act as your
representative.)

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•

Signing the notice shows only that you have received the information about your
rights. The notice does not give your discharge date (your doctor or hospital staff will
tell you your discharge date). Signing the notice does not mean you are agreeing on
a discharge date.

3. Keep your copy of the signed notice so you will have the information about making
an appeal (or reporting a concern about quality of care) handy if you need it.
•

If you sign the notice more than 2 days before the day you leave the hospital, you
will get another copy before you are scheduled to be discharged.

•

To look at a copy of this notice in advance, you can call Member Services or 1-800
MEDICARE (1-800-633-4227 or TTY: 1-877-486-2048). You can also see it online
at
http://www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage

Chapter 9
Section 7.2

Step-by-step: How to make a Level 1 Appeal
to change your hospital discharge date

If you want to ask for your hospital services to be covered by our plan for a longer time, you
will need to use the appeals process to make this request. For general information about the
appeals process, see Section 4 of this chapter. Before you start, understand what you need to
do and what the deadlines are.
•

Follow the process. Each step in the first two levels of the appeals process is
explained below.

•

Meet the deadlines. The deadlines are important. Be sure that you understand and
follow the deadlines that apply to things you must do.

•

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).

During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It
checks to see if your planned discharge date is medically appropriate for you.
When you start the appeal process by
making an appeal, it is called the “first
level of appeal” or a “Level 1 Appeal.”

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Step 1 

Contact the Quality Improvement Organization in your
state and ask for a “fast review” of your hospital
discharge. You must act quickly.

What is the Quality Improvement Organization?
•

This organization is a group of doctors and other health care professionals who are
paid by the Federal government. These experts are not part of our plan. This
organization is paid by Medicare to check on and help improve the quality of care for
people with Medicare. This includes reviewing hospital discharge dates for people
with Medicare.

How can you contact this organization?
•

The written notice you received (An Important Message from Medicare) tells you
how to reach this organization. (Or find the name, address, and phone number of the
Quality Improvement Organization for your state in Chapter 2, Section 4, of this
booklet.)

Act quickly:
•

To make your appeal, you must contact the Quality Improvement Organization before
you leave the hospital and no later than your planned discharge date. (Your
“planned discharge date” is the date that has been set for you to leave the hospital.)
o If you meet this deadline, you are allowed to stay in the hospital after your
discharge date without paying for it while you wait to get the decision on your
appeal from the Quality Improvement Organization.
o If you do not meet this deadline, and you decide to stay in the hospital after
your planned discharge date, you may have to pay all of the costs for hospital
care you receive after your planned discharge date.

•

If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to our plan instead. For details about
this other way to make your appeal, see Section 7.3.

Ask for a “fast review”:
•

You must ask the Quality Improvement Organization for a “fast review” of your
discharge. Asking for a “fast review” means you are asking for the organization to
use the “fast” deadlines for an appeal instead of using the standard deadlines.
A “fast review” is also called an “immediate
review” or an “expedited review.”

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Step 2 

The Quality Improvement Organization conducts
an independent review of your case.

What happens during this review?
•

Health professionals at the Quality Improvement Organization (we will call them “the
reviewers” for short) will ask you (or your representative) why you believe coverage
for the services should continue. You don’t have to prepare anything in writing, but
you may do so if you wish.

•

The reviewers will also look at your medical information, talk with your doctor, and
review information that the hospital and our plan has given to them.

•

During this review process, you will also get a written notice that gives your
planned discharge date and explains the reasons why your doctor, the hospital,
and our plan think it is right (medically appropriate) for you to be discharged on
that date.
This written explanation is called the “Detailed Notice
of Discharge.” (You can get a sample of this notice by
calling Member Services or 1-800-MEDICARE (1-800633-4227, 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.) Or you can get see a
sample notice online at http://www.cms.hhs.gov/BNI/).

Step 3 

Within one full day after it has all the needed
information, the Quality Improvement Organization will
give you its answer to your appeal.

What happens if the answer is yes?
•

If the review organization says yes to your appeal, our plan must keep providing
your covered hospital services for as long as these services are medically
necessary.

•

You will have to keep paying your share of the costs (such as deductibles or
copayments, if these apply). In addition, there may be limitations on your covered
hospital services. (See Chapter 4 of this booklet).

What happens if the answer is no?
•

If the review organization says no to your appeal, they are saying that your planned
discharge date is medically appropriate. (Saying no to your appeal is also called
turning down your appeal.) If this happens, our plan’s coverage for your hospital
services will end at noon on the day after the Quality Improvement Organization
gives you its answer to your appeal.

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•

If you decide to stay in the hospital, then you may have to pay the full cost of
hospital care you receive after noon on the day after the Quality Improvement
Organization gives you its answer to your appeal.

Step 4 
•

If the answer to your Level 1 appeal is no, you
decide if you want to make another appeal

If the Quality Improvement Organization has turned down your appeal, and you stay
in the hospital after your planned discharge date, then you can make another appeal.
Making another appeal means you are going on to “Level 2” of the appeals process.

Chapter 9
Section 7.3

Step-by-step: How to make a
Level 2 Appeal to change your hospital
discharge date

If the Quality Improvement Organization has turned down your appeal, and you stay in the
hospital after your planned discharge date, then you can make a Level 2 Appeal. During a Level
2 appeal, you ask the Quality Improvement Organization to take another look at the decision they
made on your first appeal.
Here are the steps for Level 2 of the appeal process:
Step 1 
•

You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this
review only if you stayed in the hospital after the date that your coverage for the care
ended.

Step 2 
•

You contact the Quality Improvement Organization
again and ask for another review

The Quality Improvement Organization does a
second review of your situation

Reviewers at the Quality Improvement Organization will take another careful look at
all of the information related to your appeal.

Step 3 

Within 14 days, the Quality Improvement
Organization reviewers will decide on your appeal
and tell you their decision.

If the review organization says yes:
•

Our plan must reimburse you for our share of the costs of hospital care you have
received since noon on the day after the date your first appeal was turned down by the

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Quality Improvement Organization. Our plan must continue providing coverage for
your hospital care for as long as it is medically necessary.
•

You must continue to pay your share of the costs and coverage limitations may
apply.

If the review organization says no:
•

It means they agree with the decision they made to your Level 1 appeal and will not
change it. This is called “upholding the decision.” It is also called “turning down your
appeal.”

•

The notice you get 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 the next level of
appeal, which is handled by a judge.
Step 4 

If the answer is no, you will need to decide
whether you want to take your appeal further
by going on to Level 3

•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If the review organization turns down your Level 2 appeal, you can
choose whether to accept that decision or whether to go on to Level 3 and make another
appeal. At Level 3, your appeal is reviewed by a judge.

•

Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Chapter 9
Section 7.4

What if you miss the deadline for making
your Level 1 Appeal?

You can appeal to our plan instead
As explained above in Section 7.2, you must act quickly to contact the Quality Improvement
Organization to start your first appeal of your hospital discharge. (“Quickly” means before you
leave the hospital and no later than your planned discharge date). If you miss the deadline for
contacting this organization, there is another way to make your appeal.
If you use this other way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for
contacting the Quality Improvement Organization, you can make an appeal to our plan, asking
for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard
deadlines.

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A “fast” review (or “fast appeal”) is
also called an “expedited” review (or
“expedited appeal”).

Step 1 

Contact our plan and ask for a “fast review.”

•

For details on how to contact our plan (including how to reach us on evenings and
weekends), go to Chapter 2, Section 1.2 and look for the section called, How to
reach our plan when you are making an appeal about your medical care.

•

Be sure to ask for a “fast review.” This means you are asking us to give you an
answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2 

Our plan does a “fast” review of your planned discharge
date, checking to see if it was medically appropriate.

•

During this review, our plan takes a look at all of the information about your hospital
stay. We check to see if your planned discharge date was medically appropriate. We
will check to see if the decision about when you should leave the hospital was fair
and followed all the rules.

•

In this situation, we will use the “fast” deadlines rather than the standard deadlines for
giving you the answer to this review.

Step 3 

Our plan gives you our decision within 24 hours
after you ask for a “fast review” (“fast appeal”).

•

If our plan says yes to your fast appeal, it means we have agreed to keep providing
your covered services for as long as it is medically necessary. It also means that we have
agreed to reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. (You must pay your share of the costs and
there may be coverage limitations that apply.)

•

If our plan says no to your fast appeal, we are saying that your planned discharge date
was medically appropriate. Our coverage for your hospital services will end on that date
and our plan will stop paying its share of the costs of this care.

•

If you stayed in the hospital after your planned discharge date, then you may have to
pay the full cost of hospital care you received after the planned discharge date.

Step 4 

If our plan says no to your fast appeal, your
case will automatically be sent on to the next

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level of the appeals process.
•

To make sure we were being fair when we said no to your fast appeal, our plan is
required to send your appeal to the “Independent Review Organization.” When we
do this, it means that you are automatically going on to Level 2 of the appeals process.

Step-by-Step: How to make a Level 2 Alternate Appeal
If our plan says no to your level 1 appeal, your case will automatically be sent on to the next
level of the appeals process. During the level 2 appeal, the Independent Review Organization
reviews the decision our plan made when we said no to your “fast 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 

•

Our plan asks the Independent Review Organization
to conduct a “fast review” of your case. (Our plan
asks for this review on your behalf.)

We are required to send the information for your Level 2 appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. The complaint process is different from the appeal process. Section 10
of this chapter tells how to make a complaint.)
Step 2 

The Independent Review Organization does a “fast
review” of your appeal. The reviewers give you an
answer within 24 hours.

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal of your hospital discharge.

•

If this organization says yes to your appeal, then our plan must reimburse you (pay you
back) for our share of the costs of hospital care you have received since the date of your
planned discharge. We must also continue the plan’s coverage of your hospital services
for as long as it is medically necessary. You must continue to pay your share of the costs.

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If there are coverage limitations, these could limit how much we would reimburse or how
long we would continue to cover your services.
•

If this organization says no to your appeal, it means they agree with our plan that your
planned hospital discharge date was medically appropriate. (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 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 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 8

Chapter 9
Section 8.1

How to ask our plan to keep covering
certain medical services if you think
your coverage is ending too soon

This section is about three services only:
Home health care, skilled nursing facility
care, and Comprehensive Outpatient
Rehabilitation Facility (CORF) services

This section is about the following types of care only:
•

Home health care services you are getting.

•

Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn
about requirements for being considered a “skilled nursing facility,” see Chapter 12,
Definitions of important words.)

•

Rehabilitation care you are getting as an outpatient at a Medicare-approved
Comprehensive Outpatient Rehabilitation Facility (CORF) services. Usually, this
means you are getting treatment for an illness or accident, or you are recovering from a
major operation. (For more about this type of facility, see Chapter 12, Definitions of
important words.)

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When you are getting any of these types of care, you have the right to keep getting your covered
services for that type of care for as long as the care is needed to diagnose and treat your illness or
injury. For more information on your covered services, including your share of the cost and any
limitations to coverage that may apply, see Chapter 4 of this booklet: Medical benefits chart
(what is covered and what you pay).
When our plan decides it is time to stop covering any of the three types of care for you, we are
required to tell you in advance. When your coverage for that care ends, our plan will stop paying
its share of the cost for your care.
If you think we are ending the coverage of your care too soon, you can ask us to keep covering
the care for a longer time and we will consider your request. This section tells you how to ask.
Chapter 9
Section 8.2

We tell you in advance when your coverage
will be ending

1. You receive a notice in writing. At least two days before our plan is going to stop
covering your care, the agency or facility that is providing your care will give you a letter
or notice.
•

The written notice tells you the date when our plan will stop covering the care for
you.
In this written notice, we are telling you about a “coverage
decision” we have made about when to stop covering your care.
(For more about coverage decisions, see Section 4 in this chapter.)

•

The written notice also tells what you can do if you want to ask our plan to change
this decision about when to end your care, and keep covering it for a longer period of
time.
In telling what you can do, the written notice is telling how you
can “make an appeal.” Making an appeal is a formal, legal way
to ask our plan to change the coverage decision we have made
about when to stop your care. (Section 9.3 below tells how you
can make an appeal.)
The written notice is called the “Notice of Medicare NonCoverage.” To get a sample copy, call Member Services or 1800-MEDICARE (1-800-633-4227, 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.). Or see a copy
online at http://www.cms.hhs.gov/BNI/.

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2. You must sign the written notice to show that you received it.
•

You or someone who is acting on your behalf must sign the notice. (Section 4 tells
how you can give written permission to someone else to act as your representative.)

•

Signing the notice shows only that you have received the information about when
your coverage will stop. Signing it does not mean you agree with the plan that it’s
time to stop getting the care.

Chapter 9
Section 8.3

Step-by-step: How to make a Level 1
Appeal to have our plan cover your
care for a longer time

If you want to ask us to cover your care for a longer period of time, you will need to use the
appeals process to make this request. For general information about the appeals process, see
Section 4 of this chapter. Before you start, understand what you need to do and what the
deadlines are.
•

Follow the process. Each step in the first two levels of the appeals process is
explained below.

•

Meet the deadlines. The deadlines are important. Be sure that you understand and
follow the deadlines that apply to things you must do. There are also deadlines our
plan must follow. (If you think we are not meeting our deadlines, you can file a
complaint. Section 10 of this chapter tells you how to file a complaint.)

•

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and
decides whether to change the decision made by our plan.
When you start the appeal process by
making an appeal, it is called the “first
level of appeal” or “Level 1 Appeal.”

Step 1 

Make your Level 1 Appeal: contact the Quality
Improvement Organization in your state and ask
for a review. You must act quickly.

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What is the Quality Improvement Organization?
•

This organization is a group of doctors and other health care experts who are paid by
the Federal government. These experts are not part of our plan. They check on the
quality of care received by people with Medicare and review plan decisions about
when it’s time to stop covering certain kinds of medical care.

How can you contact this organization?
•

The written notice you received tells you how to reach this organization. (Or find the
name, address, and phone number of the Quality Improvement Organization for your
state in Chapter 2, Section 4, of this booklet.)

What should you ask for?
•

Ask this organization to do an independent review of whether it is medically
appropriate for our plan to end coverage for your medical services.

You have one of two deadlines.
•

Your deadline for contacting the Quality Improvement Organization depends on
when you receive the written notice telling when coverage for your care will end.

o If you get the written notice 2 days before your coverage ends, you must contact
the Quality Improvement Organization to start your appeal no later than noon of
the day after you get the notice.

o If you get the notice more than 2 days before your coverage ends, you must
contact the Quality Improvement Organization to start your appeal no later than
noon of the day before the date that your coverage ends.

o (If you miss the deadline for contacting the Quality Improvement Organization
about your appeal, you can make your appeal directly to our plan instead. For
details about this other way to make your appeal, see Section 8.4.)
Step 2 

The Quality Improvement Organization conducts
an independent review of your case.

What happens during this review?
•

•

The review organization will also look at your medical information, talk with your
doctor, and review information that our plan has given to them.

•

During this review process, you will also get a written explanation from the plan
that gives our reasons for wanting to end the plan’s coverage for your services.

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This written explanation is called the
“Detailed Explanation of NonCoverage”.

Step 3 

Within one full day after they have all the
information they need, the reviewers will tell
you their decision.

What happens if the reviewers say yes to your appeal?
•

If the reviewers say yes to your appeal, then our plan must keep providing your
covered services for as long as it is medically necessary.

•

You will have to keep paying your share of the costs (such as deductibles or
copayments, if these apply). In addition, there may be limitations on your covered
services (see Chapter 4 of this booklet).

What happens if the reviewers say no to your appeal?
•

If the reviewers say no to your appeal, then your coverage will end on the date we
have told you. Our plan will stop paying its share of the costs of this care.

•

If you decide to keep getting the home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date
when your coverage ends, then you will have to pay the full cost of this care
yourself.

Step 4 

If the answer your Level 1 appeal is no, you
decide if you want to make another appeal

•

This first appeal you make is “Level 1” of the appeals process. If reviewers say no to
your Level 1 appeal – and you choose to continue getting care after your coverage for
the care has ended – then you can make another appeal.

•

Making another appeal means you are going on to “Level 2” of the appeals process.

Chapter 9
Section 8.4

Step-by-step: How to make a Level 2
Appeal to have our plan cover your
care for a longer time

If the Quality Improvement Organization has turned down your appeal and you choose to
continue getting care after your coverage for the care has ended, then you can make a Level 2

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Appeal. During a Level 2 appeal, you ask the Quality Improvement Organization to take another
look at the decision they made on your first appeal.
Here are the steps for Level 2 of the appeal process:
Step 1 
•

You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this
review only if you continued getting care after the date that your coverage for the care
ended.

Step 2 
•

You contact the Quality Improvement Organization
again and ask for another review

The Quality Improvement Organization does
a second review of your situation

Reviewers at the Quality Improvement Organization will take another careful look at
all of the information related to your appeal.

Step 3 

Within 14 days, the Quality Improvement
Organization reviewers will decide on your
appeal and tell you their decision.

What happens if the review organization says yes to your appeal?
•

Our plan must reimburse you for our share of the costs of care you have received
since the date when we said your coverage would end. Our plan must continue
providing coverage for the care for as long as it is medically necessary.

•

You must continue to pay your share of the costs and there may be coverage
limitations that apply.

What happens if the review organization says no?
•

It means they agree with the decision they made to your Level 1 appeal and will not
change it. (This is called “upholding the decision.” It is also called “turning down
your appeal.”)

•

The notice you get 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 the next
level of appeal, which is handled by a judge.

Step 4 
•

If the answer is no, you will need to decide
whether you want to take your appeal further

There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If reviewers turn down your Level 2 appeal, you can choose whether to accept

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that decision or whether to go on to Level 3 and make another appeal. At Level 3, your
appeal is reviewed by a judge.
•

Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Chapter 9
Section 8.5

What if you miss the deadline for making
your Level 1 Appeal?

You can appeal to our plan instead
As explained above in Section 9.3, you must act quickly to contact the Quality Improvement
Organization to start your first appeal (within a day or two, at the most). If you miss the deadline
for contacting this organization, there is another way to make your appeal. If you use this other
way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal
If you miss the deadline for contacting the Quality Improvement Organization, you can make an
appeal to our plan, asking for a “fast review.” A fast review is an appeal that uses the fast
deadlines instead of the standard deadlines.
Here are the steps for a Level 1 Alternate Appeal:
A “fast review” is also called an “immediate
review” or an “expedited review.”

Step 1 

Contact our plan and ask for a “fast review.”

•

Be sure to ask for a “fast review.” This means you are asking us to give you an
answer using the “fast” deadlines rather than the “standard” deadlines.

Step 2 

Our plan does a “fast” review of the decision we made
about when to stop coverage for your services.

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•

During this review, our plan takes another look at all of the information about your
case. We check to see if we were being fair and following all the rules when we set
the date for ending the plan’s coverage for services you were receiving.

•

We will use the “fast” deadlines rather than the standard deadlines for giving you the
answer to this review. (Usually, if you make an appeal to our plan and ask for a “fast
review,” we are allowed to decide whether to agree to your request and give you a
“fast review.” But in this situation, the rules require us to give you a fast response if
you ask for it.)

Step 3 

Our plan gives you our decision within 24 hours
after you ask for a “fast review” (“fast appeal”).

•

If our plan says no to your fast appeal, then your coverage will end on the date we
have told you and our plan will not pay after this date. Our plan will stop paying its share
of the costs of this care.

•

If you continued to get home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when
we said your coverage would your coverage ends, then you will have to pay the full cost
of this care yourself.
Step 4 

•

If our plan says no to your fast appeal, your
case will automatically go on to the next level
of the appeals process.

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The formal name for the “Independent
Review Organization” is the “Independent
Review Entity.” It is sometimes called the
“IRE.”

Step 1 

•

Our plan asks the Independent Review Organization
to conduct a “fast review” of your case. (Our plan
asks for this review on your behalf.)

We are required to send the information for your Level 2 appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. The complaint process is different from the appeal process. Section 11
of this chapter tells how to make a complaint.)
Step 2 

The Independent Review Organization does a “fast
review” of your appeal. The reviewers give you an
answer within 24 hours.

•

Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal.

•

If this organization says yes to your appeal, then our plan must reimburse you (pay you
back) for our share of the costs of care you have received since the date when we said
your coverage would end. We must also continue to cover the care for as long as it is
medically necessary. You must continue to pay your share of the costs. If there are
coverage limitations, these could limit how much we would reimburse or how long we
would continue to cover your services.

•

If this organization says no to your appeal, it means they agree with the decision our
plan made to your first appeal and will not change it. (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 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.
Step 3 

If the Independent Review Organization turns
down your appeal, you choose whether you want
to take your appeal further

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•

There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If reviewers say no to your Level 2 appeal, you can choose whether to accept that
decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal
is reviewed by a judge.

•

Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 9

Chapter 9
Section 9.1

Taking your appeal to Level 3 and
beyond

Levels of Appeal 3, 4, and 5

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 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
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.

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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.

•

This is the last stage of the appeals process. The Level 5 Appeal decision is final.

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Making complaints

SECTION 10

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

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 9
Section 10.1

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.

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2010 Evidence of Coverage for [insert plan name]
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Chapter 9
Section 10.2

Chapter 9
Section 10.3

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

•

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.

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•

If needed, you may ask for a “fast” complaint. 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 harm your health or hurt your ability
to function.
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.

•

The longest time we can take to answer a complaint is 30 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 in writing. Our response will
include our reasons for this answer.
Step 3 

What if you don’t like our answer?

•

You can make a complaint about our response to the Quality Improvement
Organization in your state. The name, address, and phone number of this organization is
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.

•

Each state has a different Quality Improvement Organization. This is group of doctors
and other health care experts who are paid by the Federal government. They are not part
of the plan. They check on the quality of care given to plan members and help members
when they have complaints about their care.

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Chapter 9
Section 10.4

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.

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us a written statement that explains the medical reasons for requesting an exception. For a faster
decision, include this medical information from the doctor 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 say no to your request for an exception, you can ask for a review of our decision by
making an appeal. Section 6.4 tells how to ask for an exception and how to make an
appeal if we say no.

Ask for help if you need it
•

Chapter 9
Section 10.2

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.”

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Chapter 9
Section 10.3

Step 1 

Step-by-step: Making a complaint

•

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.]

•

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.

•

Step 2 
•

We look into your complaint and
give you our answer

2010 Evidence of Coverage for [insert plan name]
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•

What if you don’t like our answer?

•

Chapter 9
Section 10.4

You can also make complaints about
quality of care to the Quality Improvement
Organization

•

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.

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181

CHAPTER 10: Ending your membership in the plan

SECTION 1. Introduction
1.1

This chapter focuses on ending your membership in our plan................................. 173

SECTION 2. When can you end your membership in our plan?
2.1

You can end your membership during the Annual Enrollment Period ................... 173

2.2

You can end your membership during the Medicare Advantage Open
Enrollment Period, but your plan choices are more limited. .................................. 174

2.3

In certain situations, you can end your membership during a Special
Enrollment Period ............................................................................................... 175

2.4

Where can you get more information about when you can end your
membership? ........................................................................................................ 176

SECTION 3. How do you end your membership in our plan?
3.1

Usually, you end your membership by enrolling in another plan ............................ 176

SECTION 4. Until your membership ends, you must keep getting your
medical services and drugs through our plan
4.1

Until your membership ends, you are still a member of our plan ............................ 178

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? ................................................... 178

5.2

We cannot ask you to leave for any reason related to your health ........................... 180

5.3

What can you do if we end your membership? ....................................................... 180

2010 Evidence of Coverage for [insert plan name]
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SECTION 1

Chapter 10
Section 1.1

182

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 medical care 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 and during the Medicare Advantage Open Enrollment Period. In certain
situations, you may also be eligible to leave the plan at other times of the year.

Chapter 10
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 Election Period”). This is the time when you should review your health [insert if
appropriate: and drug] coverage and make a decision about your coverage for the upcoming
year.

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•

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 [if applicable: 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 Advantage plan. (You can choose a plan that covers
prescription drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan
o – or – Original Medicare without a separate Medicare prescription drug plan.

•

When will your membership end? Your membership will end when your new
plan’s coverage begins on January 1.

•

What do you need to do to switch plans?
[Note: PFFS plans with drug coverage insert bullets below:]
o If you want to switch to Original Medicare and join a Medicare prescription
drug plan: Simply join the new plan. You will be disenrolled from our plan
and enrolled in Original Medicare when your new plan’s coverage.

o If you are planning on switching to Original Medicare without a drug plan:
Contact Member Services for information on how to request disenrollment.
You may also call 1-800-MEDICARE (1-800-633-4227) to request
disenrollment from our plan. TTY users should call 1-877-486-2048.
[Note: PFFS plans without drug coverage insert bullet and text below]

o If you want to switch to Original Medicare: You must request to disenroll
from our plan. For more information on how to request disenrollment contact
Member Services, or call 1-800-MEDICARE (1-800-633-4227) to request
disenrollment from our plan. TTY users should call
1-877-486-2048.
o If you are already enrolled in a Medicare prescription drug plan, you will
continue to be enrolled in your current plan. Disenrollment from our plan will
not affect your enrollment. However, if you want to join a new drug plan, you
must request enrollment in the plan of your choice. Enrollment in the new
drug plan will not automatically disenroll you from our plan.
o [Note: If the plan does not offer drug coverage, use this sentence: “If you do
not have Medicare prescription drug coverage with another plan, you can join

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184

another Medicare Advantage plan that does not offer drug coverage or you
can switch to Original Medicare.”]
•

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.

•

[MA-PD plans insert the following] 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 Advantage plan with prescription drug coverage, this means that you can
enroll in either:
o Another Medicare Advantage plan with prescription drug coverage
o – or – Original Medicare and a separate prescription drug plan.

•

[MA-only plans insert the following] 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 Advantage plan that does not include prescription drug coverage, this
means that you can enroll in either:
o Another Medicare Advantage plan that does not include prescription drug
coverage
o – or – Original Medicare. (You cannot enroll in a separate prescription drug
plan during the Medicare Advantage Open Enrollment Period.)

•

When will your membership end? Your membership will end on the first day of the
month after we get your request to change plans.

2010 Evidence of Coverage for [insert plan name]
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Chapter 10
Section 2.3

185

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 http://www.Medicare.gov:
o If you have moved.
o If you have Medicaid.
o [MA only plans: Omit this bullet.] 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 Advantage plan. (You can choose a plan that covers
prescription drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan.
o – or – Original Medicare without a separate Medicare prescription drug plan.

•

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 10
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).

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Ending your membership in the plan

•

186

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 http://www.medicare.gov. Or, you can
order a printed copy by calling Medicare at the number below.

•

You can contact the 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

Chapter 10
Section 3.1

How do you end your membership in
our plan?

You end your membership by enrolling in
another plan

Usually, to end your membership in our plan, you simply enroll in another health plan during one
of the enrollment periods (see Section 2 for information about the enrollment periods). One
exception is when you 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.
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 Advantage
plan

This is what you should do:

•

Enroll in the new Medicare Advantage
plan.
You will automatically be disenrolled
from [insert plan name] when your new
plan’s coverage begins.

•

Original Medicare with a
separate Medicare

•

Enroll in the new Medicare prescription
drug plan.

2010 Evidence of Coverage for [insert plan name]
Chapter 10: Ending your membership in the plan

If you would like to switch
from our plan to:

187

This is what you should do:

prescription drug plan.

•

Original Medicare without a
separate Medicare
prescription drug plan

SECTION 4

Chapter 10
Section 4.1

You will automatically be disenrolled
from [insert plan name] when your new
plan’s coverage begins.

•

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.

•

You will be disenrolled from [insert
plan name] when your coverage in
Original Medicare begins.

Until your membership ends, you
must keep getting your medical
services [insert if applicable: and
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 medical care [insert if applicable: and
prescription drugs] through our plan.
•

[Insert if applicable: You should continue to use our network pharmacies to get your
prescriptions filled until your membership in our plan ends. Usually, your

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188

prescription drugs are only covered if they are filled at a network pharmacy [insert if
applicable: including through our mail-order pharmacy services.]]
•

If you are hospitalized on the day that your membership ends, you will usually be
covered by our plan until you are discharged (even if you are discharged after your
new health coverage begins).

SECTION 5

Chapter 10
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 and Part B.

•

If you move out of our service area for more than [Plans without visitor/traveler benefits:
six months] [Plans with visitor/traveler benefits: [insert number up to 12] 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.
o [Plans with visitor/traveler benefits, insert: Chapter 3 and Chapter 4 give more
information about getting care when you are away from the service area.]
o [Plans with grandfathered members who were outside of area prior to January
1999, insert: If you have been a member of our plan continuously since before
January 1999 and you were living outside of our service area before January
1999, you may continue your membership. However, if you move and your move
is to another location that is outside of our service area, you will be disenrolled
from our plan.]

•

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 medical care for you and other
members of our plan.

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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 medical care.
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.

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 10
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 10
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 9, Section 10 for information about how to make
a complaint.

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CHAPTER 11: 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 11: Legal notices

SECTION 1

191

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 12: Definitions of important words

190

CHAPTER 12: 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.]
[If you use any of the following terms in your EOC, you must add a definition of the term to the
first section where you use it and here in Chapter 10 with a reference from the section where you
use it: IPA, network, PHO, plan medical group, Point of Service.]
Appeal – An appeal is a special kind of complaint you make if you disagree partially or fully
with a decision to deny a request for [health care services and/or prescription drugs] or payment
for [services and/or prescription drugs] you already received. You may also make a complaint 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/an] [drug/item/service] you think you should be able
to receive. Section 5 explains appeals, including the process involved in making an appeal.
Benefit period – For [both our Plan and] Original Medicare, a benefit period is used to
determine coverage for inpatient stays in hospitals and skilled nursing facilities. [Plans that offer
a more generous benefit period, revise the following sentences to reflect the Plan’s benefit
period.] A benefit period begins on the first day you go to a Medicare-covered inpatient hospital
or a skilled nursing facility. The benefit period ends when you haven’t been an inpatient at any
hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period
has ended, a new benefit period begins. There is no limit to the number of benefit periods you
can have.
The type of care that is covered depends on whether you are considered an inpatient for hospital
and SNF stays. You must be admitted to the hospital as an inpatient, not just under observation.
You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled
level of care. Specifically, in order to be an inpatient in a SNF, you must need daily skillednursing or skilled-rehabilitation care, or both.
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 the
Medicare. Section 8 explains how to contact CMS.

2010 Evidence of Coverage for [insert plan name]
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191

Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides
rehabilitation services after an illness or injury, and provides a variety of services including
physician's services, physical therapy, social or psychological services, and outpatient
rehabilitation.
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/services]
are received. It includes any combination of the following three types of payments: (1) any
deductible amount a plan may impose before [drugs/services] are covered; (2) any fixed
“copayment” amounts that a plan may require be paid when specific [drugs/services] are
received; or (3) any “coinsurance” amount that must be paid as a percentage of the total amount
paid for a [drug/service].
Coverage Determination – A decision from your Medicare drug plan about whether a drug
prescribed for you is covered by the plan and the amount, if any, you are required to pay for the
prescription. 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.
Covered services – The general term we use in this EOC to mean all of the health care services
and supplies that are covered by our Plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare’s standard
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.
Custodial care – Care for personal needs rather than medically necessary needs. Custodial care
is care that can be provided by people who don’t have professional skills or training. This care
includes help with walking, dressing, bathing, eating, preparation of special diets, and taking
medication. Medicare does not cover custodial care unless it is provided as other care you are
getting in addition to daily skilled nursing care and/or skilled rehabilitation services.
Deductible – The amount you must pay for the drugs you receive before our plan begins to pay
its share of your covered 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).

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Durable medical equipment – Certain medical equipment that is ordered by your doctor for use
in the home. Examples are walkers, wheelchairs, or hospital beds.
Emergency care – Covered services that are: 1) rendered by a provider qualified to furnish
emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
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
[providers/pharmacies], including a complaint concerning the quality of your care. This type of
complaint does not involve coverage or payment disputes.
Home health aide – A home health aide provides services that don’t need the skills of a licensed
nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or
carrying out the prescribed exercises). Home health aides do not have a nursing license or
provide therapy.
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.

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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. 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).

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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.
Network provider – “Provider” is the general term we use for doctors, other health care
professionals, hospitals, and other health care facilities that are licensed or certified by Medicare
and by the State to provide health care services. We call them “network providers” when they
[have an agreement with our Plan to] accept our payment as payment in full, and in some cases
to coordinate as well as provide covered services to members of our Plan. Our Plan pays network
providers based on the agreements it has with the providers or if the providers agree to provide
you with plan-covered services. Network providers may also be referred to as “plan providers.”
[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.
[Include if applicable: Optional supplemental benefits – Non-Medicare-covered benefits that
can be purchased for an additional premium and are not included in your package of benefits. If
you choose to have optional supplemental benefits, you may have to pay an additional premium.
You must voluntarily elect Optional Supplemental Benefits in order to get them.]
Organization Determination - The Medicare Advantage organization has made an organization
determination when it, or one of its providers, makes a decision about MA services or payment
that you believe you should receive.
Original Medicare – (“Traditional Medicare” or “Fee-for-service” Medicare) Original Medicare
is the way many people get their health care coverage. It is the national pay-per-visit program
that lets you go to 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. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical
Insurance) and is available everywhere in the United States.
Out-of-network provider or out-of-network facility – A provider or facility with which we
have not arranged to coordinate or provide covered services to members of our Plan. Out-ofnetwork providers are providers that are not employed, owned, or operated by our Plan or are not
under contract to deliver covered services to you. Using out-of-network providers or facilities is
explained in this EOC in Section 2.

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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 Congress permitted our plan to offer as part of a standard Medicare
prescription drug benefit. We may or may not offer all Part D drugs. (See your formulary for a
specific list of covered drugs.) Certain categories of drugs, such as benzodiazepines,
barbiturates, and over-the-counter drugs were specifically excluded by Congress from the
standard prescription drug package (see Chapter 3 for a listing of these drugs). These drugs are
not considered 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.
Primary Care [insert as appropriate: Physician OR Provider] (PCP) – A health care
professional you select to coordinate your health care. Your PCP is responsible for providing or
authorizing covered services while you are a plan member. Chapter 3 tells more about PCPs.
Preferred Provider Organization Plan – A Preferred Provider Organization plan is an MA
plan that has a network of contracted providers that have agreed to treat plan members for a
specified payment amount. A PPO plan must cover all plan benefits whether they are received
from network or out-of-network providers. Member cost-sharing may be higher when plan
benefits are received from out-of-network providers.
Prior authorization – Approval in advance to get services [if applicable: and/or certain drugs
that may or may not be on our formulary. Some drugs are covered only if your doctor or other
plan provider gets “prior authorization” from us. Covered drugs that need prior authorization
are marked in the formulary.] In a PFFS plan you do not need prior authorization to obtain
services. However, you may want to check with your plan before obtaining services to confirm
that the service is covered by your plan and what your cost share responsibility is.
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.

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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.
Rehabilitation services – These services include physical therapy, speech and language therapy,
and occupational therapy.
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.
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.

File Type	application/pdf
Author	CMS
File Modified	2009-06-18
File Created	2009-06-18