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

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

2015_PDP_ANOC_EOC_PRA_final

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⚠️ Notice: This form may be outdated.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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[PDP templates]
[2015 ANOC template]

[Insert 2015 plan name] ([insert plan type]) offered by [insert
Part D sponsor name]

Annual Notice of Changes for 2015
[Optional: insert beneficiary name]
[Optional: insert beneficiary address]
You are currently enrolled as a member of [insert 2014 plan name]. Next year, there will be
some changes to the plan’s costs and benefits. This booklet tells about the changes.
•

You have from October 15 until December 7 to make changes to your Medicare
coverage for next year.

Additional Resources
•

[Plans that meet the 5% alternative language threshold insert: This information is
available for free in other languages. Please contact our Member Services number at
[insert phone number] for additional information. (TTY users should call [insert TTY
number]). Hours are [insert days and hours of operation].] Member Services [plans that
meet the 5% threshold insert: also] has free language interpreter services available for
non-English speakers [plans that meet the 5% threshold delete the rest of this sentence]
(phone numbers are in [edit section number as needed] Section 8.1 of this booklet).

•

[Plans that meet the 5% threshold insert the paragraph above in all applicable
languages.]

•

[Plans must insert language about availability of alternate formats (e.g., Braille, large
print, audio tapes) as applicable.]

About [insert 2015 plan name]
•

[Insert Federal contracting statement.]

•

When this booklet says “we,” “us,” or “our,” it means [insert Part D sponsor name].
When it says “plan” or “our plan,” it means [insert 2015 plan name].

[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID] File & Use [MMDDYYYY]]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Think about Your Medicare Coverage for Next Year
Each fall, Medicare allows you to change your Medicare health and drug coverage during the
Annual Enrollment Period. It’s important to review your coverage now to make sure it will
meet your needs next year.

Important things to do:
 Check the changes to our benefits and costs to see if they affect you. It is important to
review benefit and cost changes to make sure they will work for you next year. Look in
Sections [insert section number] for information about benefit and cost changes for our
plan.
 Check the changes to our prescription drug coverage to see if they affect you. Will
your drugs be covered? Are they in a different tier? Can you continue to use the same
pharmacies? It is important to review the changes to make sure our drug coverage will
work for you next year. Look in Section [insert section number] for information about
changes to our drug coverage.
 Think about your overall health care costs. How much will you spend out-of-pocket
for the services and prescription drugs you use regularly? How much will you spend on
your premium? How do the total costs compare to other Medicare coverage options?
 Think about whether you are happy with our plan.

If you decide to stay with [insert 2015 plan name]:
If you want to stay with us next year, it’s easy - you don’t need to do anything. If you don’t
make a change by December 7, you will automatically stay enrolled in our plan.

If you decide to change plans:
If you decide other coverage will better meet your needs, you can switch plans between
October 15 and December 7. If you enroll in a new plan, your new coverage will begin on
January 1, 2015. Look in Section [edit section number as needed] 4.2 to learn more about
your choices.

[Insert 2015 plan name] Annual Notice of Changes for 2015

Summary of Important Costs for 2015
The table below compares the 2014 costs and 2015 costs for [insert 2015 plan name] in several
important areas. Please note this is only a summary of changes. It is important to read the
rest of this Annual Notice of Changes and review the [insert as applicable: attached OR
enclosed] Evidence of Coverage to see if other benefit or cost changes affect you.
Cost
Monthly plan premium*
*Your premium may be higher or
lower than this amount. See Section
[edit section number as needed] 2.1
for details.
Part D prescription drug coverage
(See Section [edit section number
as needed] 2.3 for details.)

2014 (this year)

2015 (next year)

[Insert 2014 premium
amount]

[Insert 2015 premium
amount]

Deductible: [Insert 2014
deductible amount]

Deductible: [Insert 2015
deductible amount]

Copays during the Initial
Coverage Stage:

•

Drug Tier 1: [Insert
2014 cost-sharing]

•

Drug Tier 1: [Insert
2015 cost-sharing]

•

[Repeat for all drug
tiers.]

•

[Repeat for all drug
tiers.]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Annual Notice of Changes for 2015
Table of Contents
[Update table below after completing edits]
Think about Your Medicare Coverage for Next Year .................................................. 1
Summary of Important Costs for 2015 ........................................................................ 2
SECTION 1

We Are Changing the Plan’s Name ................................................... 4

SECTION 1

Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2015 plan name] in 2015............. 4

SECTION 2
Changes to Benefits and Costs for Next Year ................................. 5
Section 2.1 – Changes to the Monthly Premium ...................................................................... 5
Section 2.2 – Changes to the Pharmacy Network ..................................................................... 5
Section 2.3 – Changes to Part D Prescription Drug Coverage ................................................. 6
SECTION 3

Other Changes .................................................................................. 10

SECTION 4
Deciding Which Plan to Choose...................................................... 10
Section 4.1 – If You Want to Stay in [insert 2015 plan name] .............................................. 10
Section 4.2 – If You Want to Change Plans ........................................................................... 10
SECTION 5

Deadline for Changing Plans ........................................................... 12

SECTION 6

Programs That Offer Free Counseling about Medicare ................ 12

SECTION 7

Programs That Help Pay for Prescription Drugs ........................... 12

SECTION 8
Questions?........................................................................................ 13
Section 8.1 – Getting Help from [insert 2015 plan name] ..................................................... 13
Section 8.2 – Getting Help from Medicare ............................................................................. 14

[Insert 2015 plan name] Annual Notice of Changes for 2015

[If Section 1 does not apply, plans should omit it and renumber remaining sections as needed.]

SECTION 1 We Are Changing the Plan’s Name
[Plans that are changing the plan name, as approved by CMS, include Section 1, using the
section title above and the following text:
On January 1, 2015, our plan name will change from [insert 2014 plan name] to [insert 2015
plan name].
[Insert language to inform members if they will receive new ID cards and how, as well as if the
name change will impact any other beneficiary communication.]]

SECTION 1 Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2015 plan name] in 2015
[If the beneficiary is being enrolled into another plan due to a consolidation, include Section 1,
using the section title above and the text below. It is additionally expected that, as applicable
throughout the ANOC, every plan/sponsor that crosswalks a member from a non-renewed plan
to a consolidated renewal plan will compare benefits and costs, including cost-sharing for drug
tiers, from that enrollee’s previous plan to the consolidated plan.]
On January 1, 2015, [insert Part D sponsor name] will be combining [insert 2014 plan name]
with one of our plans, [insert 2015 plan name].
If you have not done anything to change your Medicare coverage by December 7, 2014, we
will automatically enroll you in our [insert 2015 plan name]. This means starting January 1,
2015, you will be getting your prescription drug coverage through [insert 2015 plan name]. You
have choices about how to get your Medicare coverage. If you want to, you can change to a
different Medicare prescription drug plan. You can also switch to a Medicare health plan.
The information in this document tells you about the differences between your current benefits in
[insert 2014 plan name] and the benefits you will have on January 1, 2015 as a member of
[insert 2015 plan name].
[Plans that have previously notified members about the enrollment may insert the following
paragraph, editing as necessary: [Insert Part D sponsor name] mailed you a letter called
“[insert name of letter].” This letter tells you that your membership in [insert 2014 plan
name] will be ending. It has important information about the different ways you can get your
Medicare coverage, including information about how to make a change in your coverage. If
you have any questions, or if you did not receive the letter, please call Member Services
(phone numbers are in Section [edit section number as needed] 8.1 of this booklet).]]

[Insert 2015 plan name] Annual Notice of Changes for 2015

SECTION 2 Changes to Benefits and Costs for Next Year
Section 2.1 – Changes to the Monthly Premium
[Plans may add a row to this table to display changes in premiums for optional supplemental
benefits. If there is no change in premium for optional supplemental benefits, plans do not need
to insert a row.]
Cost
Monthly premium
(You must also continue to pay your
Medicare Part B premium.)

2014 (this year)

2015 (next year)

[insert 2014 premium
amount]

[insert 2015 premium
amount]

•

Your monthly plan premium will be more if you are required to pay a late enrollment
penalty.

•

If you have a higher income, you may have to pay an additional amount each month
directly to the government for your Medicare prescription drug coverage.

•

Your monthly premium will be less if you are receiving “Extra Help” with your
prescription drug costs.

Section 2.2 – Changes to the Pharmacy Network
Amounts you pay for your prescription drugs may depend on which pharmacy you
use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are
covered only if they are filled at one of our network pharmacies. [Insert if applicable: Our
network includes pharmacies with preferred cost-sharing, which may offer you lower costsharing than the standard cost-sharing offered by other pharmacies within the network.]
There are changes to our network of pharmacies for next year.
[Insert as applicable: We included a copy of our Pharmacy Directory in the envelope with this
booklet. OR An updated Pharmacy Directory is located on our website at [insert URL].] You
may also call Member Services for updated provider information or to ask us to mail you a
Pharmacy Directory. Please review the 2015 Pharmacy Directory to see which pharmacies
are in our network.

[Insert 2015 plan name] Annual Notice of Changes for 2015

Section 2.3 – Changes to Part D Prescription Drug Coverage
Changes to Our Drug List
Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is in this
envelope.
[Plans with no changes to covered drugs, tier assignment, or restrictions may replace the rest of
this section with: We have not made any changes to our Drug List for next year. The drugs
included on our Drug List will be the same in 2015 as in 2014. However, we are allowed to make
changes to the Drug List from time to time throughout the year, with approval from Medicare or
if a drug has been withdrawn from the market by either the FDA or a product manufacturer.]
We made changes to our Drug List, including changes to the drugs we cover and changes to the
restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure
your drugs will be covered next year and to see if there will be any restrictions. [If
including an abridged formulary, add the following language: The Drug List we included in this
envelope includes many – but not all – of the drugs that we will cover next year. If you don’t see
your drug on this list, it might still be covered. You can get the complete Drug List by calling
Member Services (see the back cover) or visiting our website ([insert URL]).]
If you are affected by a change in drug coverage you can:
•

Work with your doctor (or other prescriber) and ask the plan to make an exception
to cover the drug. [Plans may omit the following sentence if they allow current members
to obtain a temporary supply] Current members can ask for an exception before next
year and we will give you an answer within 72 hours after we receive your request (or
your prescriber’s supporting statement). If we approve your request, you’ll be able to get
your drug at the start of the new plan year.
o To learn what you must do to ask for an exception, see Chapter 7 of your
Evidence of Coverage (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) or call Member Services.

•

Find a different drug that we cover. You can call Member Services to ask for a list of
covered drugs that treat the same medical condition.

[Plans may omit this if they allow current members to request formulary exceptions in advance
for the following year] In some situations, we will cover a one-time, temporary supply. (To learn
more about when you can get a temporary supply and how to ask for one, see Chapter 3, Section
5.2 of the Evidence of Coverage.) 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. You can either switch to a different drug covered by the plan or ask the plan to make an
exception for you and cover your current drug.
[Plans may include additional information about processes for transitioning current enrollees to
formulary drugs when your formulary changes relative to the previous plan year.]

[Insert 2015 plan name] Annual Notice of Changes for 2015

[Include language to explain whether current formulary exceptions will still be covered next
year or a new one needs to be submitted.]
Changes to Prescription Drug Costs
Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information
about costs for Part D prescription drugs [insert as applicable: may OR does] not apply to
you. [If not applicable, omit information about the LIS Rider] We [insert as appropriate: have
included OR sent you] a separate insert, called the “Evidence of Coverage Rider for People Who
Get Extra Help Paying for Prescription Drugs” (also called the “Low Income Subsidy Rider” or
the “LIS Rider”), which tells you about your drug coverage. If you get “Extra Help” and [if plan
sends LIS Rider with ANOC, insert: didn’t receive this insert with this packet,] [if plan sends LIS
Rider separately from the ANOC, insert: haven’t receive this insert by [insert date],] please call
Member Services and ask for the “LIS Rider.” Phone numbers for Member Services are in
Section [edit section number as needed] 8.1 of this booklet.
There are four “drug payment stages.” How much you pay for a Part D drug depends on which
drug payment stage you are in. (You can look in Chapter 4, Section 2 of your Evidence of
Coverage for more information about the stages.)
The information below shows the changes for next year to the first two stages – the Yearly
Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two
stages – the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about
your costs in these stages, look at Chapter 4, Sections 6 and 7, in the [insert as applicable:
attached OR enclosed] Evidence of Coverage.)
Changes to the Deductible Stage
Stage
Stage 1: Yearly Deductible Stage
During this stage, you pay the full
cost of your [insert as applicable: Part
D OR brand name OR [tier name(s)]]
drugs until you have reached the yearly
deductible.
[Plans with no deductible, omit text
above.]

2014 (this year)
The deductible is $[insert
2014 deductible].
[Plans with no deductible
replace the text above
with: Because we have
no deductible, this
payment stage does not
apply to you.]

2015 (next year)
The deductible is
$[insert 2015
deductible].
[Plans with no
deductible replace the
text above with:
Because we have no
deductible, this payment
stage does not apply to
you.]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Changes to Your Copayments in the Initial Coverage Stage
[Plans must list all drug tiers in the table below and show costs for a one-month supply filled at
a network retail pharmacy. Plans that have pharmacies that provide preferred cost-sharing must
EITHER provide information on member cost-sharing for network pharmacies that offer
standard cost-sharing using the chart below OR provide information on both standard and
preferred cost-sharing using the second alternate chart. Plans without drug tiers may revise the
table as appropriate.]
Stage

2014 (this year)

Stage 2: Initial Coverage Stage Your cost for a one-month
supply filled at a network
[Plans with no deductible delete
pharmacy with standard
the first sentence] Once you pay
cost-sharing::
the yearly deductible, you move
to the Initial Coverage Stage.
[Insert name of Tier 1]:
During this stage, the plan pays
You pay [insert as
its share of the cost of your
applicable: $[xx] per
drugs and you pay your share
prescription OR [xx] % of the
of the cost.
total cost.]
The costs in this row are for a
[Insert name of Tier 2]:
one-month ([insert number of
days in a one-month supply]You pay [insert as
day) supply when you fill your
applicable: $[xx] per
prescription at a network
prescription OR [xx] % of the
pharmacy that provides standard total cost.]
cost-sharing. For information
about the costs [insert as
[Repeat for all tiers]
applicable: for a long-term
______________
supply; at a network pharmacy
Once [insert as applicable:
that offers preferred costyour total drugs costs have
sharing; or for mail-order
prescriptions], look in Chapter 4, reached $2,850, you will
move to the next stage (the
Section 5 of your Evidence of
Coverage Gap Stage). OR
Coverage.
you have paid $4,550 out-ofpocket
for Part D drugs, you
[Insert if applicable: We changed
will
move
to the next stage
the tier for some of the drugs on
(the Catastrophic Coverage
our Drug List. To see if your
Stage).]
drugs will be in a different tier,
look them up on the Drug List.]

2015 (next year)
Your cost for a one-month
supply filled at a network
pharmacy with standard
cost-sharing::
[Insert name of Tier 1]:
You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost.]
[Insert name of Tier 2]:
You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost.]
[Repeat for all tiers]
______________
Once [insert as applicable:
your total drugs costs have
reached $[insert 2015
initial coverage limit], you
will move to the next stage
(the Coverage Gap Stage).
OR you have paid $[insert
2015 out-of-pocket
threshold] out-of-pocket for
Part D drugs, you will
move to the next stage (the
Catastrophic Coverage
Stage).]

[Insert 2015 plan name] Annual Notice of Changes for 2015

[Plans with pharmacies that offer standard and preferred cost-sharing may replace the chart
above with the one below to provide both cost-sharing rates.]
Stage

2014 (this year)

Stage 2: Initial Coverage Stage Your cost for a one-month
supply at a network
[Plans with no deductible delete
pharmacy:
the first sentence] Once you pay
the yearly deductible, you move
[Insert name of Tier 1]:
to the Initial Coverage Stage.
Standard cost-sharing: You
During this stage, the plan pays
pay [insert as applicable:
its share of the cost of your
$[xx] per prescription OR
drugs and you pay your share
[xx]% of the total cost].
of the cost.
The costs in this row are for a
one-month ([insert number of
days in a one-month supply]day) supply when you fill your
prescription at a network
pharmacy. For information about
the costs [insert as applicable:
for a long-term supply or for
mail-order prescriptions], look in
Chapter 4, Section 5 of your
Evidence of Coverage.
[Insert if applicable: We changed
the tier for some of the drugs on
our Drug List. To see if your
drugs will be in a different tier,
look them up on the Drug List.]

Preferred cost-sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Insert name of Tier 2]:
Standard cost-sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
Preferred cost-sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
[Repeat for all tiers]
______________
Once [insert as applicable:
your total drugs costs have
reached $2,850, you will
move to the next stage (the
Coverage Gap Stage). OR
you have paid $4,550 out-ofpocket for Part D drugs, you
will move to the next stage
(the Catastrophic Coverage
Stage).]

2015 (next year)
Your cost for a one-month
supply at a network
pharmacy:
[Insert name of Tier 1]:
Standard cost-sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
Preferred cost-sharing:
You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost].
[Insert name of Tier 2]:
Standard cost-sharing: You
pay [insert as applicable:
$[xx] per prescription OR
[xx]% of the total cost].
Preferred cost-sharing:
You pay [insert as
applicable: $[xx] per
prescription OR [xx]% of
the total cost].
[Repeat for all tiers]
______________
Once [insert as applicable:
your total drugs costs have
reached $[insert 2015
initial coverage limit], you
will move to the next stage
(the Coverage Gap Stage).
OR you have paid $ [insert
2015 out-of-pocket
threshold] out-of-pocket for
Part D drugs, you will
move to the next stage (the
Catastrophic Coverage
Stage).]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Changes to the Coverage Gap and Catastrophic Coverage Stages
The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage
Stage – are for people with high drug costs. Most members do not reach the Coverage Gap
Stage or the Catastrophic Coverage Stage. For information about your costs in these stages,
look at Chapter 4, Sections 6 and 7, in your Evidence of Coverage.

SECTION 3 Other Changes
[This section is optional. Plans with administrative changes that impact members (e.g., a change
in options for paying the monthly premium, changes in prior authorization requirements, change
in contract or PBP number) may insert this section and describe the changes in the table below.
Plans that choose to omit this section should renumber the remaining sections as needed.]
Process

2014 (this year)

2015 (next year)

[insert a description of the administrative
process/item that is changing]

[insert 2014
administrative
description]

[insert 2015
administrative
description]

[insert a description of the administrative
process/item that is changing]

[insert 2014
administrative
description]

[insert 2015
administrative
description]

SECTION 4 Deciding Which Plan to Choose
Section 4.1 – If You Want to Stay in [insert 2015 plan name]
To stay in our plan you don’t need to do anything. If you do not sign up for a different plan
by December 7, you will automatically stay enrolled as a member of our plan for 2015.

Section 4.2 – If You Want to Change Plans
We hope to keep you as a member next year but if you want to change for 2015 follow these
steps:

[Insert 2015 plan name] Annual Notice of Changes for 2015

Step 1: Learn about and compare your choices
•

You can join a different Medicare prescription drug plan,

•

-- OR-- You can change to a Medicare health plan. Some Medicare health plans also
include Part D prescription drug coverage,

•

-- OR-- You can keep your current Medicare health coverage and drop your Medicare
prescription drug coverage.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare
& You 2015, call your State Health Insurance Assistance Program (see Section [edit section
number as needed] 6), or call Medicare (see Section [edit section number as needed] 8.2).
You can also find information about plans in your area by using the Medicare Plan Finder on the
Medicare website. Go to http://www.medicare.gov and click “ Find health & drug plans.” Here,
you can find information about costs, coverage, and quality ratings for Medicare plans.
[Plans may choose to insert if applicable: As a reminder, [insert Part D sponsor name] offers
other [insert as applicable: Medicare health plans AND/OR and Medicare prescription drug plans.
These other plans may differ in coverage, monthly premiums, and cost-sharing amounts.]
Step 2: Change your coverage
•

To change to a different Medicare prescription drug plan, enroll in the new plan. You
will automatically be disenrolled from [insert 2015 plan name].

•

To change to a Medicare health plan, enroll in the new plan. Depending on which type
of plan you choose, you may automatically be disenrolled from [insert 2015 plan name].
o You will automatically be disenrolled from [insert 2015 plan name] if you enroll
in any Medicare health plan that includes Part D prescription drug coverage. You
will also automatically be disenrolled if you join a Medicare HMO or Medicare
PPO, even if that plan does not include prescription drug coverage.
o If you choose a Private Fee-For-Service plan without Part D drug coverage, a
Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll
in that new plan and keep [insert 2015 plan name] for your drug coverage.
Enrolling in one of these plan types will not automatically disenroll you from
[insert 2015 plan name]. If you are enrolling in this plan type and want to leave
our plan, you must ask to be disenrolled from [insert 2015 plan name]. To ask to
be disenrolled, you must send us a written request or contact Medicare at 1-800MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY users should
call 1-877-486-2048).

•

To change to Original Medicare without a prescription drug plan, you must either:
o Send us a written request to disenroll. Contact Member Services if you need more
information on how to do this (phone numbers are in Section [edit section number
as needed] 8.1 of this booklet).

[Insert 2015 plan name] Annual Notice of Changes for 2015

o – or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-4862048.

SECTION 5 Deadline for Changing Plans
If you want to change to a different prescription drug plan or to a Medicare health plan for next
year, you can do it from October 15 until December 7. The change will take effect on January
1, 2015.
Are there other times of the year to make a change?
In certain situations, changes are also allowed at other times of the year. For example, people
with Medicaid, those who get “Extra Help” paying for their drugs, and those who move out of
the service area are allowed to make a change at other times of the year. For more information,
see Chapter 8, Section 2.2 of the Evidence of Coverage.

SECTION 6 Programs That Offer Free Counseling 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.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained
counselors in every state. In [insert state], the SHIP 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 plan choices and answer questions about switching plans. You can
call [insert state-specific SHIP name] at [insert SHIP phone number]. [Plans may insert the
following: You can learn more about [insert state-specific SHIP name] by visiting their website
([insert SHIP website]).]

SECTION 7 Programs That Help Pay for Prescription Drugs
You may qualify for help paying for prescription drugs. [Plans in states without SPAPs, delete
the next sentence] There are two basic kinds of help:
•

“Extra Help” from Medicare. People with limited incomes may qualify for “Extra
Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to
75% or more of your drug costs including monthly prescription drug premiums, annual

[Insert 2015 plan name] Annual Notice of Changes for 2015

deductibles, and coinsurance. Additionally, those who qualify will not have a coverage
gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if
you qualify, call:
o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24
hours a day/7 days a week;
o The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m.,
Monday through Friday. TTY users should call, 1-800-325-0778 (applications);
or
o Your State Medicaid Office (applications).
•

[Plans without an SPAP in their state(s), should delete this bullet.] [Organizations
offering plans in multiple states: Revise this bullet to use the generic name (“State
Pharmaceutical Assistance Program”) when necessary, and include a list of names for
all SPAPs in your service area.] Help from your state’s pharmaceutical assistance
program. [Insert state name] has a program called [insert state-specific SPAP name]
that helps people pay for prescription drugs based on their financial need, age, or medical
condition. To learn more about the program, check with your State Health Insurance
Assistance Program (the name and phone numbers for this organization are in Section
[edit section number as needed] 6 of this booklet).

•

[Plans with an ADAP in their state(s) that do NOT provide Insurance Assistance should
delete this bullet.] [Plans with no Part D drug cost-sharing should delete this section]
Prescription Cost-sharing Assistance for Persons with HIV/AIDS? The AIDS Drug
Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with
HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain
criteria, including proof of State residence and HIV status, low income as defined by the
State, and uninsured/under-insured status. Medicare Part D prescription drugs that are
also covered by ADAP qualify for prescription cost-sharing assistance through the [insert
State-specific ADAP name and information]. For information on eligibility criteria,
covered drugs, or how to enroll in the program, please call [insert State-specific ADAP
contact information].

SECTION 8 Questions?
Section 8.1 – Getting Help from [insert 2015 plan name]
Questions? We’re here to help. Please call Member Services at [insert member services phone
number]. (TTY only, call [insert TTY number].) We are available for phone calls [insert days and
hours of operation]. [Insert if applicable: Calls to these numbers are free.]

[Insert 2015 plan name] Annual Notice of Changes for 2015

Read your 2015 Evidence of Coverage (it has details about next year's benefits
and costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for
2015. For details, look in the 2015 Evidence of Coverage for [insert 2015 plan name]. The
Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your
rights and the rules you need to follow to get covered services and prescription drugs. A copy of
the Evidence of Coverage was included in this envelope.
Visit our Website
You can also visit our website at [insert URL]. As a reminder, our website has the most up-todate information about our pharmacy network (Pharmacy Directory) and our list of covered
drugs (Formulary/Drug List).

Section 8.2 – Getting Help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227)
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.
Visit the Medicare Website
You can visit the Medicare website (http://www.medicare.gov ). It has information about cost,
coverage, and quality ratings to help you compare Medicare prescription drug plans. You can
find information about plans available in your area by using the Medicare Plan Finder on the
Medicare website. (To view the information about plans, go to http://www.medicare.gov and
click on “Review and Compare Your Coverage Options.”)
Read Medicare & You 2015
You can read Medicare & You 2015 Handbook. Every year in the fall, 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), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.

[2015 EOC template]

January 1 – December 31, 2015

Evidence of Coverage:
Your Medicare Prescription Drug Coverage as a Member of [insert 2015 plan
name][insert plan type]
[Optional: insert beneficiary name]
[Optional: insert beneficiary address]
This booklet gives you the details about your Medicare prescription drug coverage from January
1 – December 31, 2015. It explains how to get coverage for the prescription drugs you need.
This is an important legal document. Please keep it in a safe place.

This plan, [insert 2015 plan name], is offered by [insert Part D sponsor name]. (When this
Evidence of Coverage says “we,” “us,” or “our,” it means [insert Part D sponsor name]. When it
says “plan” or “our plan,” it means [insert 2015 plan name].)
[Insert Federal contracting statement.]
[Plans that meet the 5% alternative language threshold insert: This information is available for
free in other languages. Please contact our Member Services number at [insert phone number]
for additional information. (TTY users should call [insert TTY number]). Hours are [insert days
and hours of operation].] Member Services [plans that meet the 5% threshold insert: also] has
free language interpreter services available for non-English speakers [plans that meet the 5%
threshold delete the rest of this sentence] (phone numbers are printed on the back cover of this
booklet).
[Plans that meet the 5% threshold insert the paragraph above in all applicable languages.]
[Plans must insert language about availability of alternate formats (e.g., Braille, large print,
audio tapes) as applicable.]
[Remove terms as needed to reflect plan benefits] Benefits, formulary, pharmacy network,
premium, deductible, and/or copayments/coinsurance may change on January 1, 2015.

[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID] File & Use [MMDDYYYY]]

2015 Evidence of Coverage for [insert 2015 plan name]
Table of Contents

2015 Evidence of Coverage
Table of Contents
This list of chapters and page numbers is your starting point. For more help in finding
information you need, go to the first page of a chapter. You will find a detailed list of topics at
the beginning of each chapter.
Chapter 1.

Getting started as a member .................................................................. 3
Explains what it means to be in a Medicare prescription drug plan and how
to use this booklet. Tells about materials we will send you, your plan
premium, your plan membership card, and keeping your membership record
up to date.

Chapter 2.

Important phone numbers and resources ........................................... 16
Tells you how to get in touch with our plan ([insert 2015 plan name]) and
with other organizations including Medicare, the State Health Insurance
Assistance Program (SHIP), the Quality Improvement Organization, Social
Security, Medicaid (the state health insurance program for people with low
incomes), programs that help people pay for their prescription drugs, and the
Railroad Retirement Board.

Chapter 3.

Using the plan’s coverage for your Part D prescription drugs .......... 33
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 coverage for certain drugs.
Explains where to get your prescriptions filled. Tells about the plan’s
programs for drug safety and managing medications.

Chapter 4.

What you pay for your Part D prescription drugs ............................... 57
Tells about the [insert number of stages] stages of drug coverage ([delete
any stages that are not applicable] Deductible Stage, Initial Coverage
Period, Coverage Gap Stage, Catastrophic Coverage Stage) and how these
stages affect what you pay for your drugs. [Plans without drug tiers, delete
the following sentence.] Explains the [insert number of tiers] cost-sharing
tiers for your Part D drugs and tells what you must pay for a drug in each
cost-sharing tier. Tells about the late enrollment penalty.

Chapter 5.

Asking us to pay our share of the costs for covered drugs .............. 84
Explains 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 drugs.

2015 Evidence of Coverage for [insert 2015 plan name]
Table of Contents

Chapter 6.

Your rights and responsibilities ........................................................... 90
Explains the rights and responsibilities you have as a member of our plan.
Tells what you can do if you think your rights are not being respected.

Chapter 7.

What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) ....................................... 100
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.

Chapter 8.

•

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

•

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

Ending your membership in the plan ................................................. 125
Explains when and how you can end your membership in the plan. Explains
situations in which our plan is required to end your membership.

Chapter 9.

Legal notices ........................................................................................ 134
Includes notices about governing law and about non-discrimination.

Chapter 10. Definitions of important words ............................................................ 136
Explains key terms used in this booklet.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

Chapter 1. Getting started as a member
SECTION 1
Section 1.1
Section 1.2
Section 1.3
Section 1.4
Section 1.5

Introduction ........................................................................................ 4
You are enrolled in [insert 2015 plan name], which is a Medicare
Prescription Drug Plan .................................................................................... 4
What is the Evidence of Coverage booklet about? .......................................... 4
What does this Chapter tell you? ..................................................................... 4
What if you are new to [insert 2015 plan name]? .......................................... 4
Legal information about the Evidence of Coverage ........................................ 5

SECTION 2
Section 2.1
Section 2.2
Section 2.3

What makes you eligible to be a plan member? .............................. 5
Your eligibility requirements .......................................................................... 5
What are Medicare Part A and Medicare Part B? ........................................... 5
Here is the plan service area for [insert 2015 plan name] .............................. 6

SECTION 3
Section 3.1
Section 3.2
Section 3.3
Section 3.4

What other materials will you get from us? ..................................... 6
Your plan membership card – Use it to get all covered prescription drugs .... 6
The Pharmacy Directory: Your guide to pharmacies in our network ............. 7
The plan’s List of Covered Drugs (Formulary) .............................................. 7
The Part D Explanation of Benefits (the “Part D EOB”): Reports with a
summary of payments made for your Part D prescription drugs .................... 8

SECTION 4
Section 4.1
Section 4.2
Section 4.3

Your monthly premium for [insert 2015 plan name] ........................ 8
How much is your plan premium? .................................................................. 8
There are several ways you can pay your plan premium .............................. 10
Can we change your monthly plan premium during the year?...................... 12

SECTION 5
Section 5.1

Please keep your plan membership record up to date ................. 12
How to help make sure that we have accurate information about you .......... 12

SECTION 6
Section 6.1

We protect the privacy of your personal health information ........ 13
We make sure that your health information is protected ............................... 13

SECTION 7
Section 7.1

How other insurance works with our plan ..................................... 14
Which plan pays first when you have other insurance? ................................ 14

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

SECTION 1

Introduction

Section 1.1

You are enrolled in [insert 2015 plan name], which is a
Medicare Prescription Drug Plan

You are covered by Original Medicare for your health care coverage, and you have chosen to
get your Medicare prescription drug coverage through our plan, [insert 2015 plan name].
There are different types of Medicare plans. [Insert 2015 plan name] is a Medicare
prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is
approved by Medicare and run by a private company.
Section 1.2

What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare prescription drug
coverage through our plan. This booklet explains your rights and responsibilities, what is
covered, and what you pay as a member of the plan.
This plan, [insert 2015 plan name], is offered by [insert Part D sponsor name]. (When this
Evidence of Coverage says “we,” “us,” or “our,” it means [insert Part D sponsor name]. When it
says “plan” or “our plan,” it means [insert 2015 plan name].)
The word “coverage” and “covered drugs” refers to the prescription drug coverage available
to you as a member of [insert 2015 plan name].
Section 1.3

What does this Chapter tell you?

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

What makes you eligible to be a plan member?

•

What is your plan’s service area?

•

What materials will you get from us?

•

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

•

How do you keep the information in your membership record up to date?

Section 1.4

What if you are new to [insert 2015 plan name]?

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

If you are confused or concerned or just have a question, please contact our plan’s Member
Services (phone numbers are printed on the back cover of this booklet).
Section 1.5

Legal information about the 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 2015 plan name]
covers your care. Other parts of this contract include your enrollment form, the List of Covered
Drugs (Formulary), and any notices you receive from us about changes to your coverage or
conditions that 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 2015 plan name]
between January 1, 2015 and December 31, 2015.
Each calendar year, Medicare allows us to make changes to the plans that we offer. This means
we can change the costs and benefits of [insert 2015 plan name] after December 31, 2015. We
can also choose to stop offering the plan, or to offer it in a different service area, after December
31, 2015.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve [insert 2015 plan
name] each year. You can continue to get Medicare coverage as a member of our plan as long as
we choose to continue to offer the plan and Medicare renews its approval of the plan.

SECTION 2

What makes you eligible to be a plan member?

Section 2.1

Your 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 have Medicare Part A or Medicare Part B (or you have both Part A and
Part B)

Section 2.2

What are Medicare Part A and Medicare Part B?

When you first signed up for Medicare, you received information about what services are
covered under Medicare Part A and Medicare Part B. Remember:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

•

Medicare Part A generally helps cover services provided by hospitals (for inpatient
services, 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) and certain items (such as durable medical equipment and
supplies).

Section 2.3

Here is the plan service area for [insert 2015 plan name]

Although Medicare is a Federal program, [insert 2015 plan name] is available only to
individuals who live in our plan service area. To remain a member of our plan, you must
continue to reside in the plan service area. The service area is described [insert as appropriate:
below OR in an appendix to this Evidence of Coverage].
[Insert plan service area here or within an appendix. Plans may include references to territories
as appropriate. Examples of the format for describing the service area are provided below:
Our service area includes all 50 states
Our service area includes these states: [insert states]]
[Optional info: multi-state plans may include the following: We offer coverage in [insert as
applicable: several OR all] states [insert if applicable: and territories]. However, there may be
cost or other differences between the plans we offer in each state. If you move out of state [insert
if applicable: or territory] and into a state [insert if applicable: or territory] that is still within our
service area, you must call Member Services in order to update your information. [National
plans delete the rest of this paragraph] If you move into a state [insert if applicable: or territory]
outside of our service area, you cannot remain a member of our plan. Please call Member
Services to find out if we have a plan in your new state [insert if applicable: or territory].]
If you plan to move out of the service area, please contact Member Services (phone numbers are
printed on the back cover of this booklet). When you move, you will have a Special Enrollment
Period that will allow you to enroll in a Medicare health or drug plan that is available in your
new location.
It is also important that you call Social Security if you move or change your mailing address.
You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

SECTION 3

What other materials will you get from us?

Section 3.1

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

While you are a member of our plan, you must use your membership card for our plan for
prescription drugs you get at network pharmacies. Here’s a sample membership card to show
you what yours will look like:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

[Insert picture of front and back of member ID card. Mark it as a sample card (for example, by
superimposing the word “sample” on the image of the card.]
Please carry your card with you at all times and remember to show your card when you get
covered drugs. If your plan membership card is damaged, lost, or stolen, call Member Services
right away and we will send you a new card. (Phone numbers for Member Services are printed
on the back cover of this booklet.)
You may need to use your red, white, and blue Medicare card to get covered medical care and
services under Original Medicare.
Section 3.2

The Pharmacy Directory: Your guide to pharmacies in our
network

What are “network pharmacies”?
Our Pharmacy Directory gives you a complete list of our network pharmacies – that means all of
the pharmacies that have agreed to fill covered prescriptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Pharmacy Directory to find the network pharmacy you want to use. [Plans may
add detail describing additional information included in the pharmacy directory.] This is
important because, with few exceptions, you must get your prescriptions filled at one of our
network pharmacies if you want our plan to cover (help you pay for) them.
[Insert if plan has pharmacies that offer preferred cost-sharing in its network: The Pharmacy
Directory will also tell you which of the pharmacies in our network have preferred cost-sharing,
which may be. lower than the standard cost-sharing offered by other network pharmacies.]
If you don’t have the Pharmacy Directory, you can get a copy from Member Services (phone
numbers are printed on the back cover of this booklet). 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.]
Section 3.3

The plan’s List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells
which Part D prescription drugs are covered by [insert 2015 plan name]. The drugs on this list
are selected by the plan with the help of a team of doctors and pharmacists. The list must meet
requirements set by Medicare. Medicare has approved the [insert 2015 plan name] Drug List.
The Drug List also tells you if there are any rules that restrict coverage for your drugs.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

We will send you a copy of the Drug List. [Insert if applicable: The Drug List we send to you
includes information for the covered drugs that are most commonly used by our members.
However, we cover additional drugs that are not included in the printed Drug List. If one of your
drugs is not listed in the Drug List, you should visit our website or contact Member Services to
find out if we cover it.] 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 printed on the back cover of this booklet).
Section 3.4

The Part D Explanation of Benefits (the “Part D EOB”): Reports
with a summary of payments made for your Part D prescription
drugs

When you use your Part D prescription drug benefits, we will send you a summary report to help
you understand and keep track of payments for your Part D prescription drugs. This summary
report is called the Part D Explanation of Benefits (or the “Part D EOB”).
The Part D Explanation of Benefits tells you the total amount you have spent on your Part D
prescription drugs and the total amount we have paid for each of your Part D prescription drugs
during the month. Chapter 4 (What you pay for your Part D prescription drugs) gives more
information about the Part D Explanation of Benefits and how it can help you keep track of your
drug coverage.
A Part D Explanation of Benefits summary is also available upon request. To get a copy, please
contact Member Services (phone numbers are printed on the back cover of this booklet).
[Note: Plans may insert other methods that members can get their Part D Explanation of
Benefits.]

SECTION 4

Your monthly premium for [insert 2015 plan name]

Section 4.1

How much is your plan premium?

As a member of our plan, you pay a monthly plan premium. [Select one of the following: For
2015, the monthly premium for [insert 2015 plan name] is [insert monthly premium amount].
OR The table below shows the monthly plan premium amount for each region we serve. OR The
table below shows the monthly plan premium amount for each plan we are offering in the service
area. OR The monthly premium amount for [insert 2015 plan name] is listed in [describe
attachment].] In addition, you must continue to pay your Medicare Part B premium (unless your
Part B premium is paid for you by Medicaid or another third party). [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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

[Insert if applicable: Your coverage is provided through a contract with your current employer or
former employer or union. Please contact the employer’s or union’s benefits administrator for
information about your plan premium.]
In some situations, your plan premium could be less
[Insert as appropriate, depending on whether SPAPs are discussed in Chapter 2: There are
programs to help people with limited resources pay for their drugs. These include “Extra Help”
and State Pharmaceutical Assistance Programs. OR The “Extra Help” program helps people with
limited resources pay for their drugs.] Chapter 2, Section 7 tells more about [insert as
applicable: these programs OR this program]. If you qualify, enrolling in the program might
lower your monthly plan premium.
If you are already enrolled and getting help from one of these programs, the information about
premiums in this Evidence of Coverage [insert as applicable: may OR does] not apply to you.
[If not applicable, omit information about the LIS Rider] We [insert as appropriate: have
included OR send you] a separate insert, called the “Evidence of Coverage Rider for People Who
Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider”
or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert,
please call Member Services and ask for the “LIS Rider.” (Phone numbers for Member Services
are printed on the back cover of this booklet.)
In some situations, your plan premium could be more
In some situations, your plan premium could be more than the amount listed above in Section
4.1. 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 because they had a continuous period of
63 days or more when they didn’t have “creditable” prescription drug coverage. (“Creditable”
means the drug coverage is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage.) For these members, the late enrollment penalty is added to the
plan’s monthly premium. Their premium amount will be the monthly plan premium plus the
amount of their late enrollment penalty.
•

If you are required to pay the late enrollment penalty, the amount of your penalty depends
on how long you waited before you enrolled in drug coverage or how many months you
were without drug coverage after you became eligible. Chapter 4, Section 10 explains the
late enrollment penalty.

•

If you have a late enrollment penalty and do not pay it, you could be disenrolled from the
plan.

Many members are required to pay other Medicare premiums
In addition to paying the monthly plan premium, many members are required to pay other
Medicare premiums. Some plan members (those who aren’t eligible for premium-free Part A)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

pay a premium for Medicare Part A. And most plan members pay a premium for Medicare Part
B.
Some people pay an extra amount for Part D because of their yearly income, this is known
Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is
$[insert amount]or above for an individual (or married individuals filing separately) or
$[insert amount]or above for married couples, you must pay an extra amount directly to
the government (not the Medicare plan) for your Medicare Part D coverage.
•

If you are required to pay the extra amount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.

•

If you have to pay an extra amount, Social Security, not your Medicare plan, will
send you a letter telling you what that extra amount will be.

•

For more information about Part D premiums based on income, go to Chapter 4,
Section 11 of this booklet. You can also visit http://www.medicare.gov on the Web or
call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY
users should call 1-800-325-0778.

Your copy of Medicare & You 2015 gives information about the Medicare premiums in the
section called “2015 Medicare Costs.” This explains how the Medicare Part B and Part D
premiums differ 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 2015 from the Medicare website
(http://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Section 4.2

There are several 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.]
If you decide to change the way you pay your premium, it can take up to three months for your
new payment method to take effect. While we are processing your request for a new payment
method, you are responsible for making sure that your plan premium is paid on time.
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). It should be emphasized that checks should
be made payable to the Plan and not CMS nor HHS. If the Plan uses coupon books, explain

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

when they will receive it and to call Member Services for a new one if they run out or lose it. In
addition, include information if you charge for bounced checks.]
Option 2: [Insert option type]
[If applicable: Insert information about other payment options. Or delete this option.
Include information about all relevant choices (e.g., automatically withdrawn from your
checking or savings account, charged directly to your credit or debit card, or billed each month
directly by the plan). 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. Please
note that furnishing discounts for enrollees who use direct payment electronic payment methods
is prohibited.]
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. (Phone numbers for Member Services are printed on the
back cover of this booklet.)
What to do if you are having trouble paying your plan premium
[Plans that do not disenroll members for non-payment may modify this section as needed.]
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 payment 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. (Phone numbers for
Member Services are printed on the back cover of this booklet.)
If we end your membership with the plan because you did not pay your premiums, and you don’t
currently have prescription drug coverage then you may not be able to receive Part D coverage
until the following year if you enroll in a new plan during the annual enrollment period. During
the annual enrollment period, you may either join a stand-alone prescription drug plan or a health
plan that also provides drug coverage. (If you go without “creditable” drug coverage for more
than 63 days, you may have to pay a late enrollment penalty for as long as you have Part D
coverage.)
If we end your membership because you did not pay your premiums, you will still have health
coverage under Original Medicare.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

[Insert if applicable: At the time we end your membership, you may still owe us for premiums
you have not paid. [Insert one or both statements as applicable for the plan: We have the right to
pursue collection of the premiums you owe. AND/OR In the future, if you want to enroll again in
our plan (or another plan that we offer), you will need to pay the amount you owe before you can
enroll.]]
If you think we have wrongfully ended your membership, you have a right to ask us to reconsider
this decision by making a complaint. Chapter 7, Section 7 of this booklet tells how to make a
complaint. If you had an emergency circumstance that was out of your control and it caused you
to not be able to pay your premiums within our grace period, you can ask Medicare to reconsider
this decision by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
Section 4.3

Can we change your monthly plan premium during the year?

No. We are not allowed to change the amount we charge for the plan’s monthly plan premium
during the year. If the monthly plan premium changes for next year we will tell you in September
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 towards 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 the
“Extra Help” program in Chapter 2, Section 7.

SECTION 5

Please keep your plan membership record up to date

Section 5.1

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

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

Let us know about these changes:
•

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

•

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

•

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

•

If you have been admitted to a nursing home

•

If your designated responsible party (such as a caregiver) changes

If any of this information changes, please let us know by calling Member Services (phone
numbers are printed on the back cover of this booklet). [Plans that allow members to update this
information on-line may describe that option here.]
It is also important to contact Social Security if you move or change your mailing address. You
can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Read over the information we send you about any other insurance coverage you
have
[Plans collecting information by phone revise heading and section as needed to reflect process.]
That’s because we must coordinate any other coverage you have with your benefits under our
plan. (For more information about how our coverage works when you have other insurance, see
Section 7 in this chapter.)
Once each year, we will send you a letter that lists any other medical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don’t need to
do anything. If the information is incorrect, or if you have other coverage that is not listed, please
call Member Services (phone numbers are printed on the back cover of this booklet).

SECTION 6

We protect the privacy of your personal health
information

Section 6.1

We make sure that your health information is protected

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.
For more information about how we protect your personal health information, please go to
Chapter 6, Section 1.4 of this booklet.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

SECTION 7

How other insurance works with our plan

Section 7.1

Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage), there are rules set by
Medicare that decide whether our plan or your other insurance pays first. The insurance that pays
first is called the “primary payer” and pays up to the limits of its coverage. The one that pays
second, called the “secondary payer,” only pays if there are costs left uncovered by the primary
coverage. The secondary payer may not pay all of the uncovered costs.
These rules apply for employer or union group health plan coverage:
•

If you have retiree coverage, Medicare pays first.

•

If your group health plan coverage is based on your or a family member’s current
employment, who pays first depends on your age, the number of people employed by
your employer, and whether you have Medicare based on age, disability, or End-stage
Renal Disease (ESRD):
o If you’re under 65 and disabled and you or your family member is still working,
your plan pays first if the employer has 100 or more employees or at least one
employer in a multiple employer plan that has more than 100 employees.
o If you’re over 65 and you or your spouse is still working, the plan pays first if the
employer has 20 or more employees or at least one employer in a multiple
employer plan that has more than 20 employees.

•

If you have Medicare because of ESRD, your group health plan will pay first for the first
30 months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:
•

No-fault insurance (including automobile insurance)

•

Liability (including automobile insurance)

•

Black lung benefits

•

Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.
If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about
who pays first, or you need to update your other insurance information, call Member Services
(phone numbers are printed on the back cover of this booklet). You may need to give your plan

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 1.
Getting started as a member

member ID number to your other insurers (once you have confirmed their identity) so your bills
are paid correctly and on time.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Chapter 2. Important phone numbers and resources
SECTION 1

[Insert 2015 plan name] contacts (how to contact us,
including how to reach Member Services at the plan) ........................ 17

SECTION 2

Medicare (how to get help and information directly from the
Federal Medicare program) ................................................................ 22

SECTION 3

State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare) ............ 23

SECTION 4

Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare) ....................... 24

SECTION 5

Social Security .................................................................................. 25

SECTION 6

Medicaid (a joint Federal and state program that helps with
medical costs for some people with limited income and
resources) .......................................................................................... 26

SECTION 7

Information about programs to help people pay for their
prescription drugs ............................................................................ 27

SECTION 8

How to contact the Railroad Retirement Board ............................. 31

SECTION 9

Do you have “group insurance” or other health insurance
from an employer? ........................................................................... 32

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

SECTION 1

[Insert 2015 plan name] contacts
(how to contact us, including how to reach Member
Services at the plan)

How to contact our plan’s Member Services
For assistance with claims, billing or member card questions, please call or write to [insert 2015
plan name] Member Services. We will be happy to help you.
Method

Member Services – Contact Information

CALL

[Insert phone number(s)]
Calls to this number are free. [Insert days and hours of operation,
including information on the use of alternative technologies.]
Member Services also has free language interpreter services available for
non-English speakers.

TTY

FAX

[Optional: insert fax number]

WRITE

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

WEBSITE

[Insert URL]

[Note: If your plan uses the same contact information for the Part D coverage determinations,
appeals, and/or complaints, you may combine the appropriate sections below.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

How to contact us when you are asking for a coverage decision about your Part D
prescription drugs
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your Part D prescription drugs. For more information on asking for coverage
decisions about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem
or complaint (coverage decisions, appeals, complaints)).
You may call us if you have questions about our coverage decision process.
Method

Coverage Decisions for Part D Prescription Drugs –
Contact Information

CALL

TTY

[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation] [Note: If you have different TTY numbers for
accepting standard and expedited coverage determinations, include both
numbers here.]

FAX

[Insert fax number] [Note: If you have different fax numbers for
accepting standard and expedited coverage determinations, include both
numbers here.]

WRITE

[Insert address] [Note: If you have different addresses for accepting
standard and expedited coverage determinations, include both addresses
here.]

WEBSITE

[Insert URL]

2015 Evidence of Coverage for [insert 2015 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
An appeal is a formal way of asking us to review and change a coverage decision we have
made. For more information on making an appeal about your Part D prescription drugs, see
Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)).
Method

Appeals for Part D Prescription Drugs – Contact Information

CALL

[Insert phone number]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation] [Note: You may also include reference to 24-hour
lines here.] [Note: You are required to accept expedited appeal requests
by phone, and may choose to accept standard appeal requests by phone.
If you choose to accept standard appeal requests by phone and you have
different numbers for accepting standard and expedited appeals, include
both numbers here.]

TTY

[Insert number]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation] [Note: You are required to accept expedited appeal
requests by phone, and may choose to accept standard appeal requests
by phone. If you choose to accept standard appeal requests by phone
and you have different TTY numbers for accepting standard and
expedited appeals, include both numbers here.]

FAX

[Insert fax number] [Note: If you have different fax numbers for
accepting standard and expedited appeals, include both numbers here.]

WRITE

[Insert address] [Note: If you have different addresses for accepting
standard and expedited appeals, include both addresses here.]

WEBSITE

[Insert URL]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

How to contact us when you are making a complaint about
your Part D prescription drugs
You can make a complaint about us or one of our network pharmacies, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If your problem is about the plan’s coverage or payment, you should look at the
section above about making an appeal.) For more information on making a complaint about
your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)).
Method

Complaints about Part D prescription drugs – Contact Information

CALL

TTY

FAX

[Optional: insert fax number] [Note: If you have different fax numbers
for accepting standard and expedited grievances, include both numbers
here.]

WRITE

[Insert address] [Note: If you have different addresses for accepting
standard and expedited grievances, include both addresses here.]

MEDICARE
WEBSITE

You can submit a complaint about [insert 2015 plan name] directly to
Medicare. To submit an online complaint to Medicare go to
www.medicare.gov/MedicareComplaintForm/home.aspx.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Where to send a request asking us to pay for our share of the cost of a drug you
have received
The coverage determination process includes determining requests to pay for our share of the
costs of a drug that you have received. For more information on situations in which you may
need to ask the plan for reimbursement or to pay a bill you have received from a provider,
see Chapter 5 (Asking us to pay our share of the costs for covered drugs).
Please note: If you send us a payment request and we deny any part of your request, you can
appeal our decision. See Chapter 7 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.
Method

Payment Requests – Contact Information

CALL

[Optional: Insert phone number and days and hours of operation]
[Note: You are required to accept payment requests in writing, and may
choose to also accept payment requests by phone.]
Calls to this number are [insert if applicable: not] free.

TTY

[Optional: Insert number] [Note: You are required to accept payment
requests in writing, and may choose to also accept payment requests by
phone.]
[Insert if plan uses a direct TTY number: This number requires special
telephone equipment and is only for people who have difficulties with
hearing or speaking.]
Calls to this number are [insert if applicable: not] free. [Insert days and
hours of operation]

FAX

[Optional: Insert fax number] [Note: You are required to accept
payment requests in writing, and may choose to also accept payment
requests by fax.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

2015 Evidence of Coverage for [insert 2015 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 Medicare Prescription Drug Plans,
including us.
Method

Medicare – Contact Information

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.
Calls to this number are free.

WEBSITE

http://www.medicare.gov
This is the official government website for Medicare. It gives you up-to-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. You
can also find Medicare contacts in your state.
The Medicare website also has detailed information about your Medicare
eligibility and enrollment options with the following tools:
•

Medicare Eligibility Tool: Provides Medicare eligibility status
information.

•

Medicare Plan Finder: Provides personalized information about
available Medicare prescription drug plans, Medicare health plans, and
Medigap (Medicare Supplement Insurance) policies in your area. These
tools provide an estimate of what your out-of-pocket costs might be in
different Medicare plans.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Method

Medicare – Contact Information

WEBSITE
(continued)

You can also use the website to tell Medicare about any complaints you have
about [insert 2015 plan name]:
•

Tell Medicare about your complaint: You can submit a complaint
about [insert 2015 plan name] directly to Medicare. To submit a
complaint to Medicare, go to
www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare
takes your complaints seriously and will use this information to help
improve the quality of the Medicare program.
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 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. (You can call Medicare at 1-800MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.)

SECTION 3

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

[Organizations offering plans in multiple states: Revise the second and third paragraphs in
this section to use the generic name (“State Health Insurance Assistance Program” or
“SHIP”), 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 information for 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. [Multiple-state plans inserting information in an exhibit, replace
rest of this paragraph with a sentence referencing the exhibit where members will find SHIP
information.] [Multiple-state plans inserting information in the EOC add: Here is a list of the
State Health Insurance Assistance Programs in each state we serve:] [Multiple-state plans
inserting information in the EOC use bullets for the following sentence, inserting separate
bullets for each state.] In [insert state], the SHIP 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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

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.
Method

[Insert state-specific SHIP name] [If the SHIP’s name does not include
the name of the state, add: ([insert state name] SHIP)] – Contact
Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: This number requires
special telephone equipment and is only for people who have difficulties
with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

SECTION 4

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

[Organizations offering plans in multiple states: Revise the second and third paragraphs of
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 for each state. [Multi-state plans inserting
information in an exhibit, replace rest of this paragraph with a sentence referencing the
exhibit where members will find QIO information.] [Multiple-state plans inserting information
in the EOC add: Here is a list of the Quality Improvement Organizations in each state we
serve:] [Multi-state plans inserting information in the EOC use bullets for the following
sentence, inserting separate bullets for each state.] For [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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

You should contact [insert state-specific QIO name] if you have a complaint about the quality
of care you have received. For example, you can contact [insert state-specific QIO name] if
you were given the wrong medication or if you were given medications that interact in a
negative way.
Method

[Insert state-specific QIO name] [If the QIO’s name does not include
the name of the state, add: ([insert state name]’s Quality Improvement
Organization)] – Contact Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the QIO uses a direct TTY number: This number requires
special telephone equipment and is only for people who have difficulties
with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

SECTION 5

Social Security

Social Security is responsible for determining eligibility and handling enrollment for
Medicare. U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal
Disease and meet 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. Social Security handles the enrollment
process for Medicare. To apply for Medicare, you can call Social Security or visit your local
Social Security office.
Social Security is also responsible for determining who has to pay an extra amount for their
Part D drug coverage because they have a higher income. If you got a letter from Social
Security telling you that you have to pay the extra amount and have questions about the
amount or if your income went down because of a life-changing event, you can call Social
Security to ask for a reconsideration.
If you move or change your mailing address, it is important that you contact Social Security to
let them know.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Method

Social Security – Contact Information

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 Social Security’s 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 ET to 7:00 pm, Monday through Friday.

WEBSITE

http://www.ssa.gov

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.
In addition, there are programs offered through Medicaid that help people with Medicare pay
their Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs”
help people with limited income and resources save money each year:
•

Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B
premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some
people with QMB are also eligible for full Medicaid benefits (QMB+).)

•

Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums.
(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

o Qualified Individual (QI): Helps pay Part B premiums.
o Qualified Disabled & Working Individuals (QDWI): Helps pay Part A
premiums.
To find out more about Medicaid and its programs, contact [insert state-specific Medicaid
agency].
Method

[Insert state-specific Medicaid agency] [If the agency’s name does not
include the name of the state, add: ([insert state name]’s Medicaid
program)] – Contact Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the state Medicaid program uses a direct TTY number: This
number requires special telephone equipment and is only for people who
have difficulties with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

SECTION 7

Information about programs to help people pay for
their prescription drugs

Medicare’s “Extra Help” Program
Medicare provides “Extra Help” to pay prescription drug costs for people who have limited
income and resources. Resources include your savings and stocks, but not your home or car. If
you qualify, you get help paying for any Medicare drug plan’s monthly premium, [insert if
applicable: yearly deductible,] and prescription [insert as applicable: copayments OR
coinsurance]. This “Extra Help” also counts toward your out-of-pocket costs.
People with limited income and resources may qualify for “Extra Help.” Some people
automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people
who automatically qualify for “Extra Help.”
You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To
see if you qualify for getting “Extra Help,” call:
•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

•

The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through
Friday. TTY users should call 1-800-325-0778 (applications); or

•

Your State Medicaid Office (applications). (See Section 6 of this chapter for contact
information.)

If you believe you have qualified for “Extra Help” and you believe that you are paying an
incorrect cost-sharing 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 (phone numbers are printed on the back cover of
this booklet).

[Plans in U.S. Territories, replace the Extra Help section with the following language if the EOC
is used for plans only in the U.S. Territories. Add the following language to the Extra Help
section if the EOC is used for plans in the U.S Territories and mainland regions: There are
programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American
Samoa to help people with limited income and resources pay their Medicare costs. Programs
vary in these areas. Call your local Medical Assistance (Medicaid) office to find out more about
their rules (phone numbers are in Section 6 of this chapter). Or call 1-800-MEDICARE (1-800633-4227) 24 hours a day, 7 days a week and say “Medicaid” for more information. TTY users
should call 1-877-486-2048. You can also visit http://www.medicare.gov for more information.]
Medicare Coverage Gap Discount Program
[Insert if the plan offers additional coverage in the gap: The Medicare Coverage Gap Discount
Program is available nationwide. Because [insert 2015 plan name] offers additional gap
coverage during the Coverage Gap Stage, your out-of-pocket costs will sometimes be lower than
the costs described here. Please go to Chapter 4, Section 6 for more information about your
coverage during the Coverage Gap Stage.]
[Insert if the plan does not have a coverage gap: The Medicare Coverage Gap Discount Program
is available nationwide. Because [insert 2015 plan name] does not have a coverage gap, the
discounts described here do not apply to you.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Instead, the plan continues to cover your drugs at your regular cost-sharing amount until you
qualify for the Catastrophic Coverage Stage. Please go to Chapter 4, Section 5 for more
information about your coverage during the Initial Coverage Stage. ]
The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name
drugs to Part D enrollees who have reached the coverage gap and are not already receiving
“Extra Help.” A 50% discount on the negotiated price (excluding the dispensing fee and vaccine
administration fee, if any) is available for those brand name drugs from manufacturers that have
agreed to pay the discount. The plan pays an additional 5% and you pay the remaining 45% for
your brand drugs.
If you reach the coverage gap, we will automatically apply the discount when your pharmacy
bills you for your prescription and your Part D Explanation of Benefits (EOB) will show any
discount provided. Both the amount you pay and the amount discounted by the manufacturer
count toward your out-of-pocket costs as if you had paid them and moves you through the
coverage gap.
You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays
35% of the price for generic drugs and you pay the remaining 65% of the price. The coverage for
generic drugs works differently than the coverage for brand name drugs. For generic drugs, the
amount paid by the plan (35%) does not count toward your out-of-pocket costs. Only the amount
you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as
part of the cost of the drug.
If you have any questions about the availability of discounts for the drugs you are taking or about
the Medicare Coverage Gap Discount Program in general, please contact Member Services
(phone numbers are printed on the back cover of this booklet).
What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?
[Plans without an SPAP in their state(s), should delete this section.]
If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program
that provides coverage for Part D drugs (other than “Extra Help”), you still get the 50% discount
on covered brand name drugs. Also, the plan pays 5% of the costs of brand drugs in the coverage
gap. The 50% discount and the 5% paid by the plan is applied to the price of the drug before any
SPAP or other coverage.
What if you have coverage from an AIDS Drug Assistance Program (ADAP)?
What is the AIDS Drug Assistance Program (ADAP)?
The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with
HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that
are also covered by ADAP qualify for prescription cost-sharing assistance [insert State-specific
ADAP information]. Note: To be eligible for the ADAP operating in your State, individuals must

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

meet certain criteria, including proof of State residence and HIV status, low income as defined
by the State, and uninsured/under-insured status.
If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D
prescription cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you
continue receiving this assistance, please notify your local ADAP enrollment worker of any
changes in your Medicare Part D plan name or policy number. [Insert State-specific ADA contact
information.]
For information on eligibility criteria, covered drugs, or how to enroll in the program, please call
[insert State-specific ADAP contact information].
What if you get “Extra Help” from Medicare to help pay your prescription drug costs?
Can you get the discounts?
No. If you get “Extra Help,” you already get coverage for your prescription drug costs during the
coverage gap.
What if you don’t get a discount, and you think you should have?
If you think that you have reached the coverage gap and did not get a discount when you paid for
your brand name drug, you should review your next Part D Explanation of Benefits (Part D
EOB) notice. If the discount doesn’t appear on your Part D Explanation of Benefits, you should
contact us to make sure that your prescription records are correct and up-to-date. If we don’t
agree that you are owed a discount, you can appeal. You can get help filing an appeal from your
State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this
Chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
State Pharmaceutical Assistance Programs
[Plans without an SPAP in their state(s), should delete this section.]
[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.
These programs provide limited income and medically needy seniors and individuals with
disabilities financial help for prescription drugs. [Multiple-state plans inserting information in an
exhibit, replace rest of this paragraph with a sentence referencing the exhibit where members
will find SPAP information.] [Multiple-state plans inserting information in the EOC add: Here is

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

a list of the State Pharmaceutical Assistance Programs in each state we serve:] [Multi-state plans
inserting information in the EOC use bullets for the following sentence, inserting separate
bullets for each state.] In [insert state name], the State Pharmaceutical Assistance Program is
[insert state-specific SPAP name].
Method

[Insert state-specific SPAP name] [If the SPAP’s name does not
include the name of the state, add: ([insert state name]’s State
Pharmaceutical Assistance Program)] – Contact Information

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the SPAP uses a direct TTY number: This number requires
special telephone equipment and is only for people who have difficulties
with hearing or speaking.]

WRITE

[Insert address]

WEBSITE

[Insert URL]

SECTION 8

How to contact the Railroad Retirement Board

The Railroad Retirement Board is an independent Federal agency that administers
comprehensive benefit programs for the nation’s railroad workers and their families. If you have
questions regarding your benefits from the Railroad Retirement Board, contact the agency.
If you receive your Medicare through the Railroad Retirement Board, it is important that you let
them know if you move or change your mailing address

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 2.
Important phone numbers and resources

Method

Railroad Retirement Board – Contact Information

CALL

1-877-772-5772
Calls to this number are free.
Available 9:00 am to 3:30 pm, Monday through Friday
If you have a touch-tone telephone, recorded information and automated
services are available 24 hours a day, including weekends and holidays.

TTY

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

http://www.rrb.gov

SECTION 9

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 as
part of this plan, you may 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. (Phone numbers for Member Services are printed
on the back cover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227;
TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan.
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

Chapter 3. Using the plan’s coverage for your Part D prescription
drugs
SECTION 1
Section 1.1
Section 1.2

Introduction ...................................................................................... 35
This chapter describes your coverage for Part D drugs ................................. 35
Basic rules for the plan’s Part D drug coverage ............................................ 36

SECTION 2

Fill your prescription at a network pharmacy [insert if
applicable: or through the plan’s mail-order service] ................... 36
To have your prescription covered, use a network pharmacy ....................... 36
Finding network pharmacies ......................................................................... 36
Using the plan’s mail-order services ............................................................. 38
How can you get a long-term supply of drugs?............................................. 39
When can you use a pharmacy that is not in the plan’s network?................. 40

Section 2.1
Section 2.2
Section 2.3
Section 2.4
Section 2.5
SECTION 3
Section 3.1
Section 3.2
Section 3.3

Your drugs need to be on the plan’s “Drug List” .......................... 41
The “Drug List” tells which Part D drugs are covered.................................. 41
There are [insert number of tiers] “cost-sharing tiers” for drugs on the
Drug List........................................................................................................ 42
How can you find out if a specific drug is on the Drug List? ....................... 42

SECTION 4
Section 4.1
Section 4.2
Section 4.3

There are restrictions on coverage for some drugs ...................... 42
Why do some drugs have restrictions? .......................................................... 42
What kinds of restrictions? ............................................................................ 43
Do any of these restrictions apply to your drugs? ......................................... 44

SECTION 5

What if one of your drugs is not covered in the way you’d
like it to be covered? ........................................................................ 44
There are things you can do if your drug is not covered in the way you’d
like it to be covered ....................................................................................... 44
What can you do if your drug is not on the Drug List or if the drug is
restricted in some way? ................................................................................. 45
What can you do if your drug is in a cost-sharing tier you think is too
high? .............................................................................................................. 48

Section 5.1
Section 5.2
Section 5.3

SECTION 6
Section 6.1
Section 6.2

What if your coverage changes for one of your drugs? ............... 49
The Drug List can change during the year .................................................... 49
What happens if coverage changes for a drug you are taking? ..................... 49

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

SECTION 7
Section 7.1

What types of drugs are not covered by the plan? ....................... 50
Types of drugs we do not cover .................................................................... 50

SECTION 8

Show your plan membership card when you fill a
prescription....................................................................................... 52
Show your membership card ......................................................................... 52
What if you don’t have your membership card with you? ............................ 52

Section 8.1
Section 8.2
SECTION 9
Section 9.1
Section 9.2
Section 9.3
Section 9.4
Section 9.5

SECTION 10
Section 10.1
Section 10.2

Part D drug coverage in special situations .................................... 52
What if you’re in a hospital or a skilled nursing facility for a stay that is
covered by Original Medicare? ..................................................................... 52
What if you’re a resident in a long-term care (LTC) facility? ...................... 53
What if you are taking drugs covered by Original Medicare? ...................... 54
What if you have a Medigap (Medicare Supplement Insurance) policy
with prescription drug coverage? .................................................................. 54
What if you’re also getting drug coverage from an employer or retiree
group plan? .................................................................................................... 54
Programs on drug safety and managing medications .................. 55
Programs to help members use drugs safely ................................................. 55
Medication Therapy Management (MTM) [insert if plan has other
medication management programs “and other”] program [insert if
applicable “s”] to help members manage their medications ......................... 56

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

Did you know there are programs to help people pay for their drugs?
[Insert as appropriate, depending on whether SPAPs are discussed in Chapter 2:
There are programs to help people with limited resources pay for their drugs. These
include “Extra Help” and State Pharmaceutical Assistance Programs. OR The “Extra
Help” program helps people with limited resources pay for their drugs.] For more
information, see Chapter 2, Section 7.
Are you currently getting help to pay for your
drugs?
If you are in a program that helps pay for your drugs, some information in this Evidence
of Coverage about the costs for Part D prescription drugs [insert as applicable: may
OR does] not apply to you. [If not applicable, omit information about the LIS Rider] We
[insert as appropriate: have included OR send you] a separate insert, called the
“Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription
Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells
you about your drug coverage. If you don’t have this insert, please call Member Services
and ask for the “LIS Rider.” (Phone numbers for Member Services are printed on the
back cover of this booklet.)

SECTION 1

Introduction

Section 1.1

This chapter describes your coverage for Part D drugs

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

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

•

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

The two examples of drugs described above are covered by Original Medicare. (To find out more
about this coverage, see your Medicare & You Handbook.) Your Part D prescription drugs are
covered under our plan.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

Section 1.2

Basic rules for the plan’s Part D drug coverage

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

You must have a provider (a doctor or other prescriber) write your prescription.

•

You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill
your prescriptions at a network pharmacy [insert if applicable: or through the plan’s
mail-order service].)

•

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

•

Your drug must be used for a medically accepted indication. A “medically accepted
indication” is a use of the drug that is either approved by the Food and Drug
Administration or supported by certain reference books. (See Section 3 for more
information about a medically accepted indication.)

SECTION 2

Fill your prescription at a network pharmacy [insert if
applicable: or through the plan’s mail-order service]

Section 2.1

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. (See Section 2.5 for information about when we would cover prescriptions filled
at out-of-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 on the plan’s Drug List.
[Include if plan has pharmacies that offer preferred cost-sharing in its networks: “Our network
includes pharmacies that offer standard cost-sharing and pharmacies that offer preferred costsharing. You may go to either type of network pharmacy to receive your covered prescription
drugs. Your cost-sharing may be less at pharmacies with preferred cost-sharing.”]
Section 2.2

Finding network pharmacies

How do you find a network pharmacy in your area?
To find a network pharmacy, you can look in your Pharmacy Directory, visit our website
([insert URL]), or call Member Services (phone numbers are printed on the back cover of this
booklet). Choose whatever is easiest for you.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

You may go to any of our network pharmacies. [Insert if plan has pharmacies that offer
preferred cost-sharing in its network: However, your costs may be even less for your covered
drugs if you use a network pharmacy that offers preferred cost-sharing rather than a network
pharmacy that offers standard cost-sharing. The Pharmacy Directory will tell you which of the
network pharmacies offer preferred cost-sharing.] [Plans in which members do not need to take
any action to switch their prescriptions may delete the following sentence.] If you switch from
one network pharmacy to another, and you need a refill of a drug you have been taking, you can
ask [insert if applicable: either to have a new prescription written by a provider 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. [Insert if applicable: Or if the pharmacy you have been using
stays within the network but is no longer offering preferred cost-sharing, you may want to switch
to a different pharmacy.] To find another network pharmacy in your area, you can get help from
Member Services (phone numbers are printed on the back cover of this booklet) or use the
Pharmacy Directory. [Insert if applicable: You can also find information on our website at
[insert website address.]
What if you need a specialized pharmacy?
Sometimes prescriptions must be filled at a specialized pharmacy. Specialized 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 (LTC) 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 (not available in Puerto Rico). 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.]

•

Pharmacies that dispense drugs that are restricted by the FDA to certain locations or
that require special handling, provider coordination, or education on their use. (Note:
This scenario should happen rarely.)

To locate a specialized pharmacy, look in your Pharmacy Directory or call Member Services
(phone numbers are printed on the back cover of this booklet).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

Section 2.3

Using the plan’s mail-order services

[Omit section if the plan does not offer mail-order services.]
[Include the following information only if your mail-order service is limited to a subset of all
formulary drugs, adapting terminology as needed: For certain kinds of drugs, you can use the
plan’s network mail-order services. Generally, the drugs provided through mail order are drugs
that you take on a regular basis, for a chronic or long-term medical condition. [Insert if plan
marks mail-order drugs in formulary: The drugs available through our plan’s mail-order service
are marked as “mail-order” drugs in our Drug List.] [Insert if plan marks non-mail-order drugs
in formulary: The drugs that are not available through the plan’s mail-order service are marked
with an asterisk in our Drug List.]]
Our plan’s mail-order service [insert either: allows OR 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 OR a [XX]-day supply].
[Plans that offer mail-order benefits with both preferred and standard cost-sharing may add
language to describe both types of cost-sharing.]
To get [insert if applicable: order forms and] information about filling your prescriptions by mail
[insert instructions].
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.]
[Each plan a sponsor offers would fall within one of three categories:
•
•
•

Plan offers no auto delivery program: Option 1 applies--none of the language below
should be provided.
Plan offers auto delivery program but sponsor has NOT received an exception from
CMS: Sponsor is expected to use language provided in both Options 2A and 2Ai below.
Plan offers auto delivery program and sponsor has received an exception from CMS:
Sponsor is expected to use language provided in both Options 2A and 2Aii below).]

[Option 1: Sponsors with no auto delivery program do not provide any of the below]
[Option 2A: Sponsors of all plans offering auto-delivery programs insert: We have an optional
automatic delivery program [sponsors may provide the name of the service by inserting “which
is called [insert name of automatic delivery program],” and substituting it as appropriate in the
remainder of this section for references to “mail order” or, as applicable, to “retail” pharmacy]
under which we will automatically fill all new prescriptions your health care provider sends to
us, as well as refills for prescriptions that have already been filled but are running out.]
[Option 2Ai: Plans that have an auto-delivery program but have not received an exception from

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

CMS insert the following: If you sign up for our optional automatic delivery program, the mailorder [sponsors of plans with retail pharmacy-based automatic delivery insert “and retail”]
pharmacy will contact you directly before shipping [if retail delivery add “or delivering”] to
make sure that you still want any drug(s) scheduled for automatic delivery. This means that the
mail-order [insert if applicable “or retail”] pharmacy will contact you before it ships [insert if
applicable “or delivers”] any refills scheduled for automatic delivery and also before it ships
[insert if applicable “or delivers”] any new prescriptions it has received from your health care
provider. This will give you an opportunity to make sure that the pharmacy is delivering the
correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or
delay the order before you are billed and it is shipped [insert if applicable “or delivered”]. It is
important that you respond each time you are contacted by your mail-order [insert if applicable
“or retail”] pharmacy to get your permission to prevent any delays in shipping [insert if
applicable “or delivery’].
So that the mail-order [insert if applicable “or retail”] pharmacy can reach you to confirm any
automatic shipments before it ships [insert if applicable “or delivers”] them, please tell us the
best ways to reach you. [Sponsors: indicate how members should inform the plan of their
communication preference.] Remember, your drugs will not be automatically shipped [insert if
applicable “or delivered”] unless you confirm you still want to receive the order.]
[Option 2Aii: Sponsors that have received an exception from CMS for 2015 from the
requirement to obtain member consent before each new fill insert the following: If you sign up
for our automatic delivery program, this allows your mail-order [insert if applicable: “or retail”]
pharmacy to fill and deliver all new prescriptions that it receives from your health care provider
without checking with you first. However, if you enroll in the automatic delivery program, the
pharmacy will still need to contact you prior to shipping any refills scheduled for automatic
delivery, to ensure that you still need that medication.
You may request automatic delivery by [insert options with specific information on how to apply
(call, e-mail, etc.]. The request for automatic deliveries of new prescriptions only lasts until the
end of the plan year ([insert last date of plan year]), 2015, and you must submit a new request
every year and/or each time you change plans. You can stop getting automatic delivery at any
time by [insert description of contact method(s)]. If you receive unneeded or unwanted drugs
through the automatic delivery program, you may be eligible for a refund of the amount you
have paid.]
Section 2.4

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

[Plans that do not offer extended-day supplies: Delete Section 2.4.]
[Insert if applicable: When you get a long-term supply of drugs, your cost-sharing may be
lower.] The plan offers [insert as appropriate: a way OR two ways] to get a long-term supply of
“maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a
regular basis, for a chronic or long-term medical condition.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

1. [Delete if plan does not offer extended-day supplies through retail pharmacies.] Some
retail pharmacies in our network allow you to get a long-term supply of maintenance
drugs. [Insert if applicable: Some of these retail pharmacies [insert if applicable: (which
offer preferred cost-sharing )] [insert if applicable: may] agree to accept [insert as
appropriate: a lower OR the mail-order] cost-sharing amount for a long-term supply of
maintenance drugs.] [Insert if applicable: Other retail pharmacies may not agree to
accept the [insert as appropriate: lower OR mail-order] cost-sharing amounts for a longterm supply of maintenance 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 long-term supply of maintenance drugs. You can also call Member Services for
more information (phone numbers are printed on the back cover of this booklet).
2. [Delete if plan does not offer mail-order service.] [Insert as applicable: For certain kinds
of drugs, you OR You] can use the plan’s network mail-order services. [Insert if plan
marks mail-order drugs in formulary, adapting as needed: The drugs available through
our plan’s mail-order service are marked as “mail-order” drugs in our Drug List.]
[Insert if plan marks non-mail-order drugs in formulary, adapting as needed: The drugs
that are not available through the plan’s mail-order service are marked with an asterisk in
our Drug List.]] Our plan’s mail-order service [insert either: allows OR 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 OR a [XX]-day supply]. See Section 2.3 for more
information about using our mail-order services.
Section 2.5

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

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

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

In these situations, please check first with Member Services to see if there is a network
pharmacy nearby. (Phone numbers for Member Services are printed on the back cover of this
booklet.)
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 your normal share of the cost) at the time you fill your prescription. You can ask us to
reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to
pay you back.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

SECTION 3

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

Section 3.1

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 use of the drug is a medically accepted indication. A
“medically accepted indication” is a use of the drug that is either:
•

approved by the Food and Drug Administration. (That is, the Food and Drug
Administration has approved the drug for the diagnosis or condition for which it is being
prescribed.)

•

-- or -- 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.)

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.
Generally, it works just as well as the brand name drug and usually costs less. There are generic
drug substitutes available for many brand name drugs.
[Insert if applicable: Our plan also covers certain over-the-counter drugs. Some over-the-counter
drugs are less expensive than prescription drugs and work just as well. For more information,
call Member Services (phone numbers are printed on the back cover of this booklet).]
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 7.1 in this chapter).

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

Section 3.2

There are [insert number of tiers] “cost-sharing tiers” for
drugs on the Drug List

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

[Plans should briefly describe each tier (e.g., Cost-Sharing Tier 1 includes generic
drugs). Indicate which is the lowest tier and which is the highest tier.]

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.
The amount you pay for drugs in each cost-sharing tier is shown in Chapter 4 (What you pay for
your Part D prescription drugs).
Section 3.3

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

You have [insert number] ways to find out:
1. Check the most recent Drug List we sent you in the mail. [Insert if applicable:
(Please note: The Drug List we send includes information for the covered drugs
that are most commonly used by our members. However, we cover additional
drugs that are not included in the printed Drug List. If one of your drugs is not
listed in the Drug List, you should visit our website or contact Member Services
to find out if we cover it.])
2. Visit the plan’s website ([insert URL]). The Drug List on the website is always
the most current.
3. Call Member Services to find out if a particular drug is on the plan’s Drug List or
to ask for a copy of the list. (Phone numbers for Member Services are printed on
the back cover of this booklet.)
4. [Plans may insert additional ways to find out if a drug is on the Drug List.]

SECTION 4

There are restrictions on coverage for some drugs

Section 4.1

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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your Part D prescription drugs

In general, our rules encourage you to get a drug that works for your medical condition and is
safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a highercost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost
option. We also need to comply with Medicare’s rules and regulations for drug coverage and
cost-sharing.
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If you want us to waive the restriction for
you, you will need to use the coverage decision process and ask us to make an exception. We
may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for
information about asking for exceptions.)
Please note that sometimes a drug may appear more than once in our drug list. This is because
different restrictions or cost-sharing may apply based on factors such as the strength, amount, or
form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one
per day versus two per day; tablet versus liquid).
Section 4.2

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.]
Restricting brand name drugs when a generic version is available
Generally, a “generic” drug works the same as a brand name drug and usually costs less. [Insert
as applicable: In most cases, when OR When] a generic version of a brand name drug is
available, our network pharmacies will provide you the generic version. We usually will not
cover the brand name drug when a generic version is available. However, if your provider [insert
as applicable: has told us the medical reason that the generic drug will not work for you OR has
written “No substitutions” on your prescription for a brand name drug OR has told us the medical
reason that neither the generic drug nor other covered drugs that treat the same condition will
work for you], then we will cover the brand name drug. (Your share of the cost may be greater
for the brand name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your provider need to get approval from the plan before we will agree to
cover the drug for you. This is called “prior authorization.” 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.

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Trying a different drug first
This requirement encourages you to try less costly but just as 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.
Section 4.3

Do any of these restrictions apply to your drugs?

The plan’s Drug List includes information about the restrictions described above. To find out if
any of these restrictions apply to a drug you take or want to take, check the Drug List. For the
most up-to-date information, call Member Services (phone numbers are printed on the back
cover of this booklet) or check our website ([insert URL]).
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If there is a restriction on the drug you
want to take, you should contact Member Services to learn what you or your provider would
need to do to get coverage for the drug. If you want us to waive the restriction for you, you will
need to use the coverage decision process and ask us to make an exception. We may or may not
agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking
for exceptions.)

SECTION 5

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

Section 5.1

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

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

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

•

What if the drug is covered, but there are extra rules or restrictions on coverage for
that drug? As explained in Section 4, some of the drugs covered by the plan have extra

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rules to restrict their use. For example, [delete if plan does not have step therapy: you
might be required to try a different drug first, to see if it will work, before the drug you
want to take will be covered for you.] [Delete if plan does not have quantity limits: Or
there might be limits on what amount of the drug (number of pills, etc.) is covered during
a particular time period.] In some cases, you may want us to waive the restriction for you.
For example, [delete if plan does not have step therapy: you might want us to cover a
certain drug for you without having to try other drugs first.] [Delete if plan does not have
quantity limits: Or you may want us to cover more of a drug (number of pills, etc.) than
we normally will cover.]
•

[Omit if plan’s formulary structure (e.g., no tiers) does not allow for tiering exceptions]
What if the drug is covered, but it is in a cost-sharing tier that makes your costsharing more expensive than you think it should be? The plan puts each covered drug
into one of [insert number of tiers] different cost-sharing tiers. How much you pay for
your prescription depends in part on which cost-sharing tier your drug is in.

There are things you can do if your drug is not covered in the way that you’d like it to be
covered. [Delete next sentence if plan’s formulary structure (e.g., no tiers) does not allow for
tiering exceptions] Your options depend on what type of problem you have:
•

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

•

[Omit if plan’s formulary structure (e.g., no tiers) does not allow for tiering exceptions]
If your drug is in a cost-sharing tier that makes your cost more expensive than you think
it should be, go to Section 5.3 to learn what you can do.

Section 5.2

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 the drug (only members in certain
situations can get a temporary supply). This will give you and your provider time to
change to another drug or to file a request to have the drug covered.

•

You can change to another drug.

•

You can request an exception and ask the plan to cover the drug or remove restrictions
from the drug.

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 provider about the change in coverage and figure out what to do.

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To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
•
•

The drug you have been taking is no longer on the plan’s Drug List.
-- or -- the drug you have been taking is now restricted in some way (Section 4 in this
chapter tells about restrictions).

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

[Sponsors may omit this scenario if the plan allows current members to request
formulary exceptions in advance for the following year] For those members who were
in the plan last year and aren’t in a long-term care (LTC) facility:
We will cover a temporary supply of your drug 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)]. If your prescription
is written for fewer days, we will allow multiple fills to provide up to a maximum of
[insert supply limit (must be at least a 30-day supply)] of medication. The prescription
must be filled at a network pharmacy.

•

For those members who are new to the plan and aren’t in a long-term care (LTC)
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. This temporary supply will
be for a maximum of [insert supply limit (must be at least a 30-day supply)]. If your
prescription is written for fewer days, we allow multiple fills to provide up to a maximum
of [insert supply limit (must be at least a 30-day supply)] of medication. The prescription
must be filled at a network pharmacy.

•

For those members who were in the plan last year and reside in a long-term care
(LTC) 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 total supply will be for
a maximum of [insert supply limit (must be at least a 91-day supply and may be up to a
98-day supply depending on the dispensing increment)]. If your prescription is written for
fewer days, we will allow multiple fills to provide up to a maximum of [insert time period
(must be at least a 91-day supply)] of medication. (Please note that the long-term care
pharmacy may provide the drug in smaller amounts at a time to prevent waste.)

2015 Evidence of Coverage for [insert 2015 plan name]
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•

For those members who are new to the plan and reside in a long-term care (LTC)
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 total supply will be for
a maximum of [insert supply limit (must be at least a 91-day supply and may be up to a
98-day supply depending on the dispensing increment)]. If your prescription is written for
fewer days, we will allow multiple fills to provide up to a maximum of [insert time period
(must be at least a 91-day supply)] of medication. (Please note that the long-term care
pharmacy may provide the drug in smaller amounts at a time to prevent waste.).

•

For those members who have been in the plan for more than [insert time period
(must be at least 90 days)] and reside in a long-term care (LTC) facility and need a
supply right away:
We will cover one [insert supply limit (must be at least a 31-day supply)] supply, or less
if your prescription is written for fewer days. This is in addition to the above long-term
care transition supply.

•

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

To ask for a temporary supply, call Member Services (phone numbers are printed on the back
cover of this booklet).
During the time when you are getting a temporary supply of a drug, you should talk with your
provider to decide what to do when your temporary supply runs out. You can either switch to a
different drug covered by the plan or ask the plan to make an exception for you and cover your
current drug. The sections below tell you more about these options.
You can change to another drug
Start by talking with your provider. 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 provider find a covered drug that
might work for you. (Phone numbers for Member Services are printed on the back cover of this
booklet.)
You can ask for an exception
You and your provider 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 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.

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[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 next year. You can ask for an exception before next year and we will give you
an answer within 72 hours after we receive your request (or your prescriber’s supporting
statement). If we approve your request, we will authorize the coverage before the change takes
effect.
If you and your provider want to ask for an exception, Chapter 7, Section 5.4 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 5.3

What can you do if your drug is in a cost-sharing tier you think
is too high?

[Plans with a formulary structure (e.g., no tiers) that does not allow for tiering exceptions, omit
this sentence.] If your drug is in a cost-sharing tier you think is too high, here are things you can
do:
You can change to another drug
If your drug is in a cost-sharing tier you think is too high, start by talking with your provider.
Perhaps there is a different drug in a lower cost-sharing tier 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 provider find a covered drug that might work for you. (Phone
numbers for Member Services are printed on the back cover of this booklet.)
[Plans with a formulary structure (e.g., no tiers) that does not allow for tiering
exceptions, omit this section] You can ask for an exception
For drugs in [insert tier(s)], you and your provider can ask the plan to make an exception in the
cost-sharing tier for the drug so that you pay less for it. If your 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.
If you and your provider want to ask for an exception, Chapter 7, Section 5.4 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.
[Insert if applicable: Drugs in some of our cost-sharing tiers are not eligible for this type of
exception. We do not lower the cost-sharing amount for drugs in [insert tier name(s)].]

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SECTION 6

What if your coverage changes for one of your
drugs?

Section 6.1

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 decide not to cover it. Or we might remove
a drug from the list because it has been found to be ineffective.

•

[Plans that do not use tiers may omit] Move a drug to a higher or lower cost-sharing
tier.

•

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

•

Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug
List.
Section 6.2

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

How will you find out if your drug’s coverage has been changed?
If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell
you. Normally, we will let you know at least 60 days ahead of time.
Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other
reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will
let you know of this change right away. Your provider 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 tiers may omit] If we move your drug into a higher cost-sharing
tier.

•

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

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•

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

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

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

•

Again, 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 provider will also know about this change, and can work with you to find
another drug for your condition.

SECTION 7

What types of drugs are not covered by the plan?

Section 7.1

Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” This means Medicare
does not pay for these drugs.
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 [insert if applicable: (except for certain excluded drugs covered
under our enhanced 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 it
because of your specific situation. (For information about appealing a decision we have made to
not cover a drug, go to Chapter 7, Section 5.5 in this booklet.)

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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 cannot cover a drug purchased outside the United States and its territories.

•

Our plan usually cannot cover off-label use. “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 Generally, coverage for “off-label use” 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: [Insert if
applicable: (Our plan covers certain drugs listed below through our enhanced drug coverage, for
which you may be charged an additional premium. More information is provided below.):]
•

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

•

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

[Insert if applicable: We offer additional coverage of some prescription drugs not normally
covered in a Medicare prescription drug plan (enhanced drug coverage). [Insert details about the
excluded drugs your plan does cover, including whether you place any limits on that coverage.]
The amount you pay when you fill a prescription for these drugs does not count towards
qualifying you for the Catastrophic Coverage Stage. (The Catastrophic Coverage Stage is
described in Chapter 4, Section 7 of this booklet.)]
[Insert if plan offers coverage for any drugs excluded under Part D: In addition, if you are
receiving “Extra Help” from Medicare to pay for your prescriptions, the “Extra Help”
program will not pay for the drugs not normally covered. (Please refer to the plan’s Drug List or
call Member Services for more information. Phone numbers for Member Services are printed on

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the back cover of this booklet.) However, if you have drug coverage through Medicaid, 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. (You can find phone numbers and contact information for Medicaid in Chapter
2, Section 6.)]
[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. (You can find
phone numbers and contact information for Medicaid in Chapter 2, Section 6.)]

SECTION 8

Show your plan membership card when you fill a
prescription

Section 8.1

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 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.
Section 8.2

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

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

SECTION 9

Part D drug coverage in special situations

Section 9.1

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

If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will
generally cover the cost of your prescription drugs during your stay. Once you leave the hospital,
our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the
previous parts of this chapter that tell about the rules for getting drug coverage.

2015 Evidence of Coverage for [insert 2015 plan name]
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If you are admitted to a skilled nursing facility for a stay covered by Original Medicare,
Medicare Part A will generally cover your prescription drugs during all or part of your stay. If
you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan
will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous
parts of this chapter that tell about the rules for getting drug coverage.
Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a
Special Enrollment Period. During this time period, you can switch plans or change your
coverage. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan
and join a different Medicare plan.)
Section 9.2

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

Usually, a long-term care facility (LTC) (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 (phone
numbers are printed on the back cover of this booklet).
What if you’re a resident in a long-term care (LTC) 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 total supply will be for a maximum of [insert supply limit (must be at
least a 91-day supply and may be up to a 98-day supply depending on the dispensing
increment)], or less if your prescription is written for fewer days. (Please note that the long-term
care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) 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
provider 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 provider 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 provider want to ask for an exception, Chapter 7, Section 5.4 tells what
to do.

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Section 9.3

What if you are taking drugs covered by Original Medicare?

Your enrollment in [insert 2015 plan name] doesn’t affect your coverage for drugs covered
under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will
still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In
addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it,
even if you choose not to enroll in Part A or Part B.
Some drugs may be covered under Medicare Part B in some situations and through [insert 2015
plan name] in other situations. But drugs are never covered by both Part B and our plan at the
same time. In general, your pharmacist or provider will determine whether to bill Medicare Part
B or [insert 2015 plan name] for the drug.
Section 9.4

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

If you currently have a Medigap policy that includes coverage for prescription drugs, you must
contact your Medigap issuer and tell them you have enrolled in our plan. If you decide to keep
your current Medigap policy, your Medigap issuer will remove the prescription drug coverage
portion of your Medigap policy and lower your premium.
Each year your Medigap insurance company should send you a notice that tells if your
prescription drug coverage is “creditable,” and the choices you have for drug coverage. (If the
coverage from the Medigap policy is “creditable,” it means that it is expected to pay, on
average, at least as much as Medicare’s standard prescription drug coverage.) The notice will
also explain how much your premium would be lowered if you remove the prescription drug
coverage portion of your Medigap policy. If you didn’t get this notice, or if you can’t find it,
contact your Medigap insurance company and ask for another copy.
Section 9.5

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

Do you currently have other prescription drug coverage through your (or your spouse’s)
employer or retiree group? If so, please contact that group’s benefits administrator. He or
she can help you determine how your current prescription drug coverage will work with our
plan.
In general, if you are currently employed, the prescription drug coverage you get from us will be
secondary to your employer or retiree group coverage. That means your group coverage would
pay first.

2015 Evidence of Coverage for [insert 2015 plan name]
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Special note about ‘creditable coverage’:
Each year your employer or retiree group should send you a notice that tells if your prescription
drug coverage for the next calendar year is “creditable” and the choices you have for drug
coverage.
If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that
is expected to pay, on average, at least as much as Medicare’s standard prescription drug
coverage.
Keep these notices about creditable coverage, because you may need them later. If you enroll
in a Medicare plan that includes Part D drug coverage, you may need these notices to show that
you have maintained creditable coverage. If you didn’t get a notice about creditable coverage
from your employer or retiree group plan, you can get a copy from the employer or retiree
group’s benefits administrator or the employer or union.

SECTION 10

Programs on drug safety and managing medications

Section 10.1

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 provider to
correct the problem.

2015 Evidence of Coverage for [insert 2015 plan name]
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Section 10.2

Medication Therapy Management (MTM) [insert if plan has
other medication management programs “and other”] program
[insert if applicable “s”] to help members manage their
medications

[Plans should include this section only if applicable.]
We have a program [delete “a” and insert “programs” if plan has other medication management
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.
This program is [if applicable replace with “These programs are”] voluntary and free to
members. A team of pharmacists and doctors developed the program [insert if applicable “s”] for
us. This program [insert if applicable: “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. Our [if applicable replace “Our” with “One”] program is called a Medication
Therapy Management (MTM) program. Some members who take several medications for
different medical conditions may qualify. A pharmacist or other health professional will give you
a comprehensive review of all your medications. You can talk about how best to take your
medications, your costs, or any problems you’re having. You’ll get a written summary of this
discussion. The summary has a medication action plan that recommends what you can do to
make the best use of your medications, with space for you to take notes or write down any
follow-up questions. You’ll also get a personal medication list that will include all the
medications you’re taking and why you take them.
It’s a good idea to schedule your medication review before your yearly “Wellness” visit, so you
can talk to your doctor about your action plan and medication list. Bring your action plan and
medication list with you to your visit or anytime you talk with your doctors, pharmacists, and
other health care providers. Also, take your medication list with you if you go to the hospital or
emergency room.
If we have a program that fits your needs, we will automatically enroll you in the program and
send you information. If you decide not to participate, please notify us and we will withdraw you
from the program. If you have any questions about these programs, please contact Member
Services (phone numbers are printed on the back cover of this booklet).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Chapter 4. What you pay for your Part D prescription drugs
SECTION 1
Section 1.1
Section 1.2
SECTION 2
Section 2.1
SECTION 3
Section 3.1
Section 3.2
SECTION 4
Section 4.1

SECTION 5
Section 5.1
Section 5.2
Section 5.3
Section 5.4
Section 5.5

Section 5.6

Introduction ...................................................................................... 59
Use this chapter together with other materials that explain your drug
coverage......................................................................................................... 59
Types of out-of-pocket costs you may pay for covered drugs ...................... 60
What you pay for a drug depends on which “drug payment
stage” you are in when you get the drug ....................................... 60
What are the drug payment stages for [insert 2015 plan name] members?.. 60
We send you reports that explain payments for your drugs
and which payment stage you are in .............................................. 62
We send you a monthly report called the “Part D Explanation of
Benefits” (the “Part D EOB”) ....................................................................... 62
Help us keep our information about your drug payments up to date ............ 62
During the Deductible Stage, you pay the full cost of your
[insert drug tiers if applicable] drugs ............................................. 63
You stay in the Deductible Stage until you have paid $[insert deductible
amount] for your [insert drug tiers if applicable] drugs............................... 63
During the Initial Coverage Stage, the plan pays its share of
your drug costs and you pay your share ....................................... 64
What you pay for a drug depends on the drug and where you fill your
prescription .................................................................................................... 64
A table that shows your costs for a one-month supply of a drug .................. 65
If your doctor prescribes less than a full month’s supply, you may not
have to pay the cost of the entire month’s supply ......................................... 66
A table that shows your costs for a long-term ([insert if applicable: up to
a] [insert number of days]-day) supply of a drug ......................................... 67
You stay in the Initial Coverage Stage until your [insert as applicable:
total drug costs for the year reach $[insert 2015 initial coverage limit] OR
out-of-pocket costs for the year reach $ [insert 2015 out-of-pocket
threshold]....................................................................................................... 68
How Medicare calculates your out-of-pocket costs for prescription drugs... 69

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

SECTION 6

Section 6.1
Section 6.2
SECTION 7
Section 7.1

During the Coverage Gap Stage, [insert as appropriate: you
receive a discount on brand name drugs and pay no more
than 65% of the costs for generic drugs OR the plan
provides some drug coverage] ....................................................... 72
You stay in the Coverage Gap Stage until your out-of-pocket costs reach
$[insert 2015 out-of-pocket threshold] ......................................................... 72
How Medicare calculates your out-of-pocket costs for prescription drugs... 73
During the Catastrophic Coverage Stage, the plan pays
most of the cost for your drugs ...................................................... 75
Once you are in the Catastrophic Coverage Stage, you will stay in this
stage for the rest of the year .......................................................................... 75

SECTION 8
Section 8.1

Additional benefits information....................................................... 76
Our plan offers additional benefits ................................................................ 76

SECTION 9

What you pay for vaccinations covered by Part D depends
on how and where you get them ..................................................... 76
Our plan has separate coverage for the Part D vaccine medication itself
and for the cost of giving you the vaccination shot ....................................... 76
You may want to call us at Member Services before you get a vaccination . 78

Section 9.1
Section 9.2
SECTION 10
Section 10.1
Section 10.2
Section 10.3
Section 10.4

Do you have to pay the Part D “late enrollment penalty”? ........... 78
What is the Part D “late enrollment penalty”? .............................................. 78
How much is the Part D late enrollment penalty? ......................................... 79
In some situations, you can enroll late and not have to pay the penalty ....... 79
What can you do if you disagree about your late enrollment penalty? ......... 80

SECTION 11

Do you have to pay an extra Part D amount because of your
income?............................................................................................. 80
Who pays an extra Part D amount because of income? ................................ 80
How much is the extra Part D amount? ......................................................... 82
What can you do if you disagree about paying an extra Part D amount? ..... 83
What happens if you do not pay the extra Part D amount? ........................... 83

Section 11.1
Section 11.2
Section 11.3
Section 11.4

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Did you know there are programs to help people pay for their drugs?
[Insert as appropriate, depending on whether SPAPs are discussed in Chapter 2:
There are programs to help people with limited resources pay for their drugs. These
include “Extra Help” and State Pharmaceutical Assistance Programs. OR The “Extra
Help” program helps people with limited resources pay for their drugs.] For more
information, see Chapter 2, Section 7.
Are you currently getting help to pay for your drugs?
If you are in a program that helps pay for your drugs, some information in this Evidence
of Coverage about the costs for Part D prescription drugs [insert as applicable: may
OR does] not apply to you. [If not applicable, omit information about the LIS Rider] We
[insert as appropriate: have included OR send you] a separate insert, called the
“Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription
Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells
you about your drug coverage. If you don’t have this insert, please call Member Services
and ask for the “LIS Rider.” (Phone numbers for Member Services are printed on the
back cover of this booklet.)

SECTION 1

Introduction

Section 1.1

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

This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple,
we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 3, not
all drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and other
drugs are excluded from Medicare coverage by law. [Optional for plans that provide
supplemental coverage: Some excluded drugs may be covered by our plan if you have purchased
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

o [Plans that do not use tiers, omit] It also tells which of the [insert number of tiers]
“cost-sharing tiers” 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
printed on the back cover of this booklet). You can also find the Drug List on our
website at [insert URL]. The Drug List on the website is always the most current.
•

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

•

The plan’s Pharmacy Directory. In most situations you must use a network pharmacy to
get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list
of pharmacies in the plan’s network. It also tells you which pharmacies in our network
can give you a long-term supply of a drug (such as filling a prescription for a threemonth’s supply).

Section 1.2

Types of out-of-pocket costs you may pay for covered drugs

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 amount that you pay for
a drug is called “cost-sharing,” and there are three ways you may be asked to pay.
•

The “deductible” is the amount you must pay for drugs before our plan begins to pay its
share.

•

“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.

SECTION 2

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

Section 2.1

What are the drug payment stages for [insert 2015 plan name]
members?

As shown in the table below, there are “drug payment stages” for your prescription drug
coverage under [insert 2015 plan name]. 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. [Plans with no
premium delete the following sentence] Keep in mind you are always responsible for the plan’s
monthly premium regardless of the drug payment stage.
[Plans: Ensure entire table appears on the same page.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
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

[Plans with no gap
coverage insert: During
this stage, you pay 45%
of the price for brand
name drugs plus a
portion of the dispensing
fee) and 65% of the
price for generic drugs.]

During this stage, the
plan will pay most
of the cost of your
drugs for the rest of
the calendar year
(through December
31, 2015).

[If plan has a
deductible for all tiers
insert: You begin in
this payment stage
when you fill your first
prescription of the
year.]
During this stage, you
pay the full cost of
your [insert if
applicable: brand
name OR [tier
name(s)]] drugs.
You stay in this stage
until you have paid
$[insert deductible
amount] for your
[insert if applicable:
brand name OR [tier
name(s)]] drugs
($[insert deductible
amount] is the amount
of your [insert if
applicable: brand
name OR [tier
name(s)]] deductible).
(Details are in Section
4 of this chapter.)
[Plans with no
deductible replace the
text above with:
Because there is no
deductible for the plan,
this payment stage
does not apply to you.]

[Insert if plan has no
deductible: You begin in
this stage when you fill
your first prescription of
the year.]
[Insert if plan has no
deductible or a deductible
that applies to all drugs:
During this stage, the
plan pays its share of the
cost of your drugs and
you pay your share of
the cost.]
[Insert if plan has a
deductible that applies to
some drugs: During this
stage, the plan pays its
share of the cost of your
[insert if applicable:
generic OR [tier name(s)]]
drugs and you pay your
share of the cost.
After you (or others on
your behalf) have met
your [insert if applicable:
brand name OR [tier
name(s)]] deductible, the
plans pays its share of
the costs of your [insert if
applicable: brand name
OR [tier name(s)]] drugs
and you pay your share.]
You stay in this stage
until your year-to-date
[insert as applicable:
“total drug costs” (your
payments plus any Part D
plan’s payments) total
$[insert 2015 initial
coverage limit]. OR “outof-pocket costs” (your
payments) reach $ [insert
2015 out-of-pocket
threshold].]
(Details are in Section 5
of this chapter.)

[Plans with generic
coverage only in the gap
insert:
For generic drugs, you
pay [plans should briefly
describe generic
coverage. E.g., either a
$10 copayment or 65%
of the costs, whichever
is lower]. For brand
name drugs, you pay
45% of the price (plus a
portion of the dispensing
fee).]
[Plans with some
coverage in the gap:
insert description of gap
coverage using standard
terminology.]
You stay in this stage
until your year-to-date
“out-of-pocket costs”
(your payments) reach a
total of $ [insert 2015
out-of-pocket threshold].
This amount and rules
for counting costs
toward this amount have
been set by Medicare.
(Details are in Section 6
of this chapter.)
[Plans with no additional
coverage gap replace
the text above with:
Because there is no
coverage gap for the
plan, this payment stage
does not apply to you.]

(Details are in
Section 7 of this
chapter.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

SECTION 3

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

Section 3.1

We send you a monthly report called the “Part D Explanation
of Benefits” (the “Part D EOB”)

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 have paid. 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
or others pay on your behalf plus the amount paid by the plan.

Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimes
called the “EOB”) when you have had one or more prescriptions filled through the plan during
the previous month. It includes:
•

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

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
keep track of your out-of-pocket costs. 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 pay our share of the cost. For instructions on
how to do this, go to Chapter 5, Section 2 of this booklet.) Here are some types of
situations when you may want to give 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

o When you made a copayment for drugs that are provided under a drug
manufacturer patient assistance program.
o Any time you have purchased covered drugs at out-of-network pharmacies or
other times you have paid the full price for a covered drug under special
circumstances.
•

Send us information about the payments others have made for you. Payments made
by certain other individuals and organizations also count toward your out-of-pocket costs
and help qualify you for catastrophic coverage. For example, payments made by [plans
without an SPAP in their state delete next item] a State Pharmaceutical Assistance
Program, an AIDS drug assistance program (ADAP), the Indian Health Service, and most
charities count toward your out-of-pocket costs. You should keep a record of these
payments and send them to us so we can track your costs.

•

Check the written report we send you. When you receive a Part D Explanation of
Benefits (an EOB) 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 printed on the back cover of this
booklet). [Plans that allow members to manage this information on-line may describe
that option here.] Be sure to keep these reports. They are an important record of your
drug expenses.

SECTION 4

During the Deductible Stage, you pay the full cost of
your [insert drug tiers if applicable] drugs

Section 4.1

You stay in the Deductible Stage until you have paid $[insert
deductible amount] for your [insert drug tiers if applicable]
drugs

[Plans with no deductible replace Section 4 title with: There is no deductible for [insert 2015
plan name].]
[Plans with no deductible replace Section 4.1 title with: You do not pay a deductible for your
Part D drugs.]
[Plans with no deductible replace text below with: There is no deductible for [insert 2015 plan
name]. You begin in the Initial Coverage Stage when you fill your first prescription of the year.
See Section 5 for information about your coverage in the Initial Coverage Stage.]
The Deductible Stage is the first payment stage for your drug coverage. [Plans with a deductible
for all drug types/tiers, insert: This stage begins when you fill your first prescription in the year.
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 2015.] [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 tiers] drugs. You must pay the full cost of your

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

[insert applicable drug tiers] 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.

•

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 [insert drug tiers if applicable] drugs,
you leave the Deductible Stage and move on to the next drug payment stage, which is the Initial
Coverage Stage.

SECTION 5

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

Section 5.1

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

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription
drugs, and you pay your share (your [insert as applicable: copayment OR coinsurance amount
OR copayment or coinsurance amount]). Your share of the cost will vary depending on the drug
and where you fill your prescription.
The plan has [insert number of tiers] Cost-Sharing Tiers
[Plans that do not use drug tiers should omit this section.]
Every drug on the plan’s Drug List is in one of [insert number of tiers] cost-sharing tiers. In
general, the higher the cost-sharing tier number, the higher your cost for the drug:
•

[Plans should briefly describe each tier (e.g., Cost-Sharing Tier 1 includes generic
drugs). Indicate which is the lowest tier and which is the highest tier.]

To find out which cost-sharing tier 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:
•

[Plans with retail network pharmacies that offer preferred cost-sharing, delete this bullet
and use next two bullets instead] A retail pharmacy that is in our plan’s network

•

[Plans with retail network pharmacies that offer preferred cost-sharing, insert: A
network retail pharmacy that offers standard cost-sharing]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

•

[Plans with retail network pharmacies that offer preferred cost-sharing, insert: A
network retail pharmacy that offers preferred cost-sharing

•

A pharmacy that is not in the plan’s network

•

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

For more information about these pharmacy choices and filling your prescriptions, see Chapter 3
in this booklet and the plan’s Pharmacy Directory.
[Include if plan has network pharmacies that offer preferred cost-sharing. Generally, we will
cover your prescriptions only if they are filled at one of our network pharmacies. Some of our
network pharmacies also offer preferred cost-sharing. You may go to either network pharmacies
that offer preferred cost-sharing or other network pharmacies that offer standard cost-sharing to
receive your covered prescription drugs. Your costs may be less at pharmacies that offer
preferred cost-sharing.]
Section 5.2

A table that shows your costs for a one-month 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 Stage, 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 tiers, omit] As shown in the table below, the amount of the
copayment or coinsurance depends on which tier your drug is in. Please note:
•

[Plans without copayments, omit] If your covered drug costs less than the copayment
amount listed in the chart, you will pay that lower price for the drug. You pay either the
full price of the drug or the copayment amount, whichever is lower.

•

We cover prescriptions filled at out-of-network pharmacies in only limited situations.
Please see Chapter 3, Section 2.5 for information about when we will cover a
prescription filled at an out-of-network pharmacy.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Your share of the cost when you get a one-month supply of a covered Part D
prescription drug:
Standard
retail-costsharing (innetwork)
(up to a [insert
number of
days]-day
supply)

Preferred
retail costsharing (innetwork)
(up to a [insert
number of
days]-day
supply)

Mail-order
cost-sharing
(up to a [insert
number of
days]-day
supply)

Long-term
care (LTC)
cost-sharing
(up to a [insert
number of
days]-day
supply)

Out-of-network
cost-sharing
(Coverage is limited
to certain situations;
see Chapter 3 for
details.)
(up to a [insert
number of days]-day
supply)

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

[Insert copay/
coinsurance]

Cost-Sharing
Tier 2
([insert
description])

[Insert copay/
coinsurance]

Cost-Sharing
Tier 3
([insert
description])

[Insert copay/
coinsurance]

Cost-Sharing
Tier 4
([insert
description])

[Insert copay/
coinsurance]

Tier

Section 5.3

If your doctor prescribes less than a full month’s supply, you
may not have to pay the cost of the entire month’s supply

Typically, you pay a copay to cover a full month’s supply of a covered drug. However your
doctor can prescribe less than a month’s supply of drugs. There may be times when you want to
ask your doctor about prescribing less than a month’s supply of a drug (for example, when you
are trying a medication for the first time that is known to have serious side effects). If you doctor
agrees, you will not have to pay for the full month’s supply for certain drugs.
The amount you pay when you get less than a full month’s supply will depend on whether you
are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat
dollar amount).
•

If you are responsible for coinsurance, you pay a percentage of the total cost of the drug.
You pay the same percentage regardless of whether the prescription is for a full month’s

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

supply or for fewer days. However, because the entire drug cost will be lower if you get
less than a full month’s supply, the amount you pay will be less.
•

If you are responsible for a copayment for the drug, your copay will be based on the
number of days of the drug that you receive. We will calculate the amount you pay per
day for your drug (the “daily cost-sharing rate”) and multiply it by the number of days of
the drug you receive.
o [If the plan’s one month’s supply is not 30 days, edit the number of days in and
the copay for a full month’s supply. For example, if the plan’s one-month supply
is 28 days, revise the information in the next two bullets to reflect a 28-day supply
of drugs and a $28 copay.] Here’s an example: Let’s say the copay for your drug
for a full month’s supply (a 30-day supply) is $30. This means that the amount
you pay per day for your drug is $1. If you receive a 7 days’ supply of the drug,
your payment will be $1 per day multiplied by 7 days, for a total payment of $7.
o You should not have to pay more per day just because you begin with less than a
month’s supply. Let’s go back to the example above. Let’s say you and your
doctor agree that the drug is working well and that you should continue taking the
drug after your 7 days’ supply runs out. If you receive a second prescription for
the rest of the month, or 23 days more of the drug, you will still pay $1 per day, or
$23. Your total cost for the month will be $7 for your first prescription and $23
for your second prescription, for a total of $30 – the same as your copay would be
for a full month’s supply.

Daily cost-sharing allows you to make sure a drug works for you before you have to pay for an
entire month’s supply.
Section 5.4

A table that shows your costs for a long-term ([insert if
applicable: up to a] [insert number of days]-day) supply of a
drug

[Plans that do not offer extended-day supplies delete Section 5.4.]
For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill
your prescription. A long-term supply is [insert if applicable: up to] a [insert number of days]day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 3,
Section 2.4.)
The table below shows what you pay when you get a long-term ([insert if applicable: up to a]
[insert number of days]-day) supply of a drug.
•

[Plans without copayments, omit] Please note: If your covered drug costs less than the
copayment amount listed in the chart, you will pay that lower price for the drug. You
pay either the full price of the drug or the copayment amount, whichever is lower.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

[If the plan has retail network pharmacies that offer preferred cost-sharing, the chart must
include both standard and preferred cost-sharing rates. For plans that offer mail-order benefits
with both preferred and standard cost-sharing, sponsors may at their option modify the chart to
indicate the different rates. If any columns do not apply to the plan (e.g., preferred cost-sharing
or mail order), remove them from the table. The plan may also add or remove tiers as necessary.
If mail order is not available for certain tiers, plans should insert the following text in the costsharing cell: “Mail order is not available for drugs in [insert tier].”]
[Plans must include all of their tiers in the table. If plans do not offer extended-day supplies for
certain tiers, the plan should use the following text in the cost-sharing cell: “A long-term
supply is not available for drugs in [insert tier].”]
Your share of the cost when you get a long-term supply of a covered Part D
prescription drug:

Tier

Standard retail costsharing (in-network)
([insert if applicable: up
to a] [insert number of
days]-day supply)

Preferred retail costsharing (in-network)
([insert if applicable: up
to a] [insert number of
days]-day supply)

Mail-order costsharing([insert if
applicable: up to a]
[insert number of
days]-day supply)

Cost-Sharing Tier 1
([insert description])

[Insert copay/
coinsurance]

Cost-Sharing Tier 2
([insert description])

[Insert copay/
coinsurance]

Cost-Sharing Tier 3
([insert description])

[Insert copay/
coinsurance]

Cost-Sharing Tier 4
([insert description])

[Insert copay/
coinsurance]

Section 5.5

You stay in the Initial Coverage Stage until your [insert as
applicable: total drug costs for the year reach $[insert 2015
initial coverage limit] OR out-of-pocket costs for the year reach
$ [insert 2015 out-of-pocket threshold]

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 any Part D plan
has paid:
•

What you have paid for all the covered drugs you have gotten since you started with
your first drug purchase of the year. (See Section 6.2 for more information about how
Medicare calculates your out-of-pocket costs.) This includes:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

o [Plans without a deductible, omit] The $[insert deductible amount] you paid when
you were in the 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. (If you were enrolled in a different Part D plan at any time during 2015,
the amount that plan paid during the Initial Coverage Stage also counts toward your total
drug costs.)

[Plans with no additional coverage gap replace the text above with: You stay in the Initial
Coverage Stage until your total out-of-pocket costs reach $ [insert 2015 out-of-pocket threshold].
Medicare has rules about what counts and what does not count as your out-of-pocket costs. (See
Section 5.5 for information about how Medicare counts your out-of-pocket costs.) When you
reach an out-of-pocket limit of $ [insert 2015 out-of-pocket threshold], you leave the Initial
Coverage Gap and move on to the Catastrophic 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 [insert if plan has a coverage gap: initial coverage limit or total out-ofpocket 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 (EOB) that we send to you will help you keep track of how much
you and the plan, as well as any third parties, have spent on your behalf during the year. Many
people do not reach the [insert as applicable: $[insert initial coverage limit] OR $ [insert 2015
out-of-pocket threshold]] limit in a year.
We will let you know if you reach this [insert as applicable: $[insert initial coverage limit] OR $
[insert 2015 out-of-pocket threshold]] amount. If you do reach this amount, you will leave the
Initial Coverage Stage and move on to the [insert as applicable: Coverage Gap Stage OR
Catastrophic Coverage Stage].
Section 5.6

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

[Plans no additional coverage gap: insert Section 5.6]
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 2015 out-of-pocket threshold], you leave the
Initial Coverage Stage and move on to the Catastrophic Coverage Stage.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs
for your 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 3 of this booklet):
o The amount you pay for drugs when you are in any of the following drug payment
stages:
o

[Plans without a deductible, omit] The Deductible Stage.

The Initial Coverage Stage.

o Any payments you made during this calendar year as a member of a different Medicare
prescription drug plan before you joined our plan.
It matters who pays:
o If you make these payments yourself, they are included in your out-of-pocket costs.
o 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, by AIDS drug assistance programs, [plans without an
SPAP in their state delete next item] by a State Pharmaceutical Assistance Program
that is qualified by Medicare, or by the Indian Health Service. Payments made by
Medicare’s “Extra Help” Program are also included.
o Some of the payments made by the Medicare Coverage Gap Discount Program are
included. The amount the manufacturer pays for your brand name drugs is included.
But the amount the plan pays for your generic drugs is not included.
Moving on to the Catastrophic Coverage Stage:
When you (or those paying on your behalf) have spent a total of $ [insert 2015 out-of-pocket
threshold] in out-of-pocket costs within the calendar year, you will move from the Initial
Coverage Stage to the Catastrophic Coverage Stage.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
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:
o [Plans with no premium, omit] The amount you pay for your monthly premium.
o Drugs you buy outside the United States and its territories.
o Drugs that are not covered by our plan.
o Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements
for out-of-network coverage.
o [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:
o Prescription drugs covered by Part A or Part B.
o Payments you make toward drugs covered under our additional coverage but not
normally covered in a Medicare Prescription Drug Plan.]
o [Insert if applicable: Payments you make toward prescription drugs not normally
covered in a Medicare Prescription Drug Plan.]
o Payments made by the plan for your generic drugs while in the Coverage Gap.
o Payments for your drugs that are made by group health plans including employer
health plans.
o Payments for your drugs that are made by certain insurance plans and governmentfunded health programs such as TRICARE and the Veteran’s Administration.
o 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 printed on the back cover of this booklet).

How can you keep track of your out-of-pocket total?

o We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to
you includes the current amount of your out-of-pocket costs (Section 3 in this chapter
tells about this report). When you reach a total of $[insert 2015 out-of-pocket
threshold]in out-of-pocket costs for the year, this report will tell you that you have left
the Initial Coverage Stage and have moved on to the Catastrophic Coverage Stage.
o Make sure we have the information we need. Section 3.2 tells what you can do to help
make sure that our records of what you have spent are complete and up to date.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

SECTION 6

During the Coverage Gap Stage, [insert as
appropriate: you receive a discount on brand name
drugs and pay no more than 65% of the costs for
generic drugs OR the plan provides some drug
coverage]

Section 6.1

You stay in the Coverage Gap Stage until your out-of-pocket
costs reach $[insert 2015 out-of-pocket threshold]

[Plans with no additional coverage gap replace Section 6 title with: There is no coverage gap for
[insert 2015 plan name].]
[Plans with no additional coverage gap replace Section 6.1 title with: You do not have a
coverage gap for your Part D drugs.]
[Plans with no additional coverage gap replace text below with: There is no coverage gap for
[insert 2015 plan name]. Once you leave the Initial Coverage Stage, you move on to the
Catastrophic Coverage Stage. See Section 7 for information about your coverage in the
Catastrophic Coverage Stage.]
[Plans with some coverage in the gap, revise the text below as needed to describe the plan’s
coverage.]
When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program
provides manufacturer discounts on brand name drugs. You pay 45% of the negotiated price
(excluding the dispensing fee and vaccine administration fee, if any) for brand name drugs. Both
the amount you pay and the amount discounted by the manufacturer count toward your out-ofpocket costs as if you had paid them and moves you through the coverage gap.
You also receive some coverage for generic drugs. You pay no more than 65% of the cost for
generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (35%)
does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you
through the coverage gap.
You continue paying the discounted price for brand name drugs and no more than 65% of the
costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that
Medicare has set. In 2015, that amount is $ [insert 2015 out-of-pocket threshold].
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 2015 out-of-pocket threshold], you leave the
Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Section 6.2

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

[Plans with no additional coverage gap: delete Section 6.2]
Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs
for your drugs.

•

The amount you pay for drugs when you are in any of the following drug payment
stages:
o

[Plans without a deductible, omit] The Deductible Stage.

The Initial Coverage Stage.

[Plans without a coverage gap, omit] The Coverage Gap Stage.

Any payments you made during this calendar year as a member of a different
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, by AIDS drug assistance programs,
[plans without an SPAP in their state delete next item] by a State Pharmaceutical
Assistance Program that is qualified by Medicare, or by the Indian Health Service.
Payments made by Medicare’s “Extra Help” Program are also included.

•

Some of the payments made by the Medicare Coverage Gap Discount Program
are included. The amount the manufacturer pays for your brand name drugs is
included. But the amount the plan pays for your generic drugs is not included.

Moving on to the Catastrophic Coverage Stage:
When you (or those paying on your behalf) have spent a total of $[insert 2015 out-of-pocket
threshold] in out-of-pocket costs within the calendar year, you will move from the [insert as
applicable: Initial Coverage Stage OR Coverage Gap Stage] to the Catastrophic Coverage
Stage.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
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 made by the plan for your generic drugs while in the Coverage Gap.

•

Payments for your drugs that are made by group health plans including employer
health plans.

•

Payments for your drugs that are made by certain insurance plans and governmentfunded health programs such as TRICARE and the Veteran’s Administration.

•

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 printed on the back cover of this booklet).

How can you keep track of your out-of-pocket total?
•

We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to
you includes the current amount of your out-of-pocket costs (Section 3 in this chapter
tells about this report). When you reach a total of $[insert 2015 out-of-pocket threshold]
in out-of-pocket costs for the year, this report will tell you that you have left the [insert
as applicable: Initial Coverage Stage OR Coverage Gap Stage] and have moved on to
the Catastrophic Coverage Stage.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

•

Make sure we have the information we need. Section 3.2 tells what you can do to
help make sure that our records of what you have spent are complete and up to date.

SECTION 7

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

Section 7.1

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 2015 out-of-pocket threshold] 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 2015 catastrophic cost-sharing amount for generics/preferred
multisource drugs] for a generic drug or a drug that is treated like a generic and
$[Insert 2015 catastrophic cost-sharing amount for all other drugs] 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.
[If plan provides coverage for excluded drugs as a supplemental benefit, insert a description of
cost-sharing in the Catastrophic Coverage Stage.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

SECTION 8

Additional benefits information

Section 8.1

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

What you pay for vaccinations covered by Part D
depends on how and where you get them

Section 9.1

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

Our plan provides coverage of a number of Part D 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 Part D vaccination?
What you pay for a Part D vaccination depends on three things:
1. The type of vaccine (what you are being vaccinated for).
o Some vaccines are considered Part D drugs. You can find these vaccines listed in
the plan’s List of Covered Drugs (Formulary).
o Other vaccines are considered medical benefits. They are covered under Original
Medicare.
2. Where you get the vaccine medication.
3. Who gives you the vaccination shot.
What you pay at the time you get the Part D 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

•

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 Part D 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 OR Coverage
Gap Stage OR Deductible and Coverage Gap Stage] of your benefit.]
Situation 1:

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

Situation 2:

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

Situation 3:

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

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

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 for Member Services are printed on the back 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

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

Section 10.1

What is the Part D “late enrollment penalty”?

Note: If you receive “Extra Help” from Medicare to pay for your prescription drugs, you will not
pay a late enrollment penalty.
The late enrollment penalty is an amount that is added to you Part D premium. You may owe a
late enrollment penalty if at any time after your initial enrollment period is over, there is a period
of 63 days or more in a row when you did not have Part D or other creditable prescription drug
coverage. “Creditable prescription drug coverage” is coverage that meets Medicare’s minimum
standards since it is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage. The amount of the penalty depends on how long you waited to enroll
in a creditable prescription drug coverage plan any time after the end of your initial enrollment
period or how many full calendar months you went without creditable prescription drug
coverage. You will have to pay this penalty for as long as you have Part D coverage.
The penalty is added to your monthly premium. [Plans that do not allow quarterly premium
payments, omit the next sentence] (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 2015 plan name], we let you know the amount of the penalty.
Your late enrollment penalty is considered part of your plan premium. [Insert the following text if
the plan disenrolls for failure to pay premiums: If you do not pay your late enrollment penalty,
you could be disenrolled for failure to pay your plan premium.]
[Plans with no plan premium, replace the previous two paragraphs with the following language:
When you first enroll in [insert 2015 plan name], we let you know the amount of the penalty.
Your late enrollment penalty is considered your plan premium. [Insert the following text if the

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

plan disenrolls for failure to pay premiums: If you do not pay your late enrollment penalty, you
could be disenrolled from the plan.]]
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 did not
have creditable 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
example, if you go 14 months without coverage, the penalty 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 2015, this average
premium amount is $[insert 2015 national base beneficiary premium] OR For 2014, this
average premium amount was $[insert 2014 national base beneficiary premium]. This
amount may change for 2015.]

•

To calculate your monthly penalty, you multiply the penalty percentage and the average
monthly premium and then round it to the nearest 10 cents. In the example here it would
be 14% times $[insert base beneficiary premium], which equals $[insert amount]. This
rounds to $[insert amount]. This amount would be added to the monthly premium for
someone with a late enrollment penalty.

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

First, the penalty may 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
period for aging into Medicare.

Section 10.3

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

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

If you already have prescription drug coverage that is expected to pay, on average, at
least as much as Medicare’s standard prescription drug coverage. Medicare calls this
“creditable drug coverage.” Please note:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

o Creditable coverage could include drug coverage from a former employer or
union, TRICARE, or the Department of Veterans Affairs. Your insurer or your
human resources department will tell you each year if your drug coverage is
creditable coverage. This information may be sent to you in a letter or included in
a newsletter from the plan. Keep this information, because you may need it if you
join a Medicare drug plan later.


Please note: If you receive a “certificate of creditable coverage” when
your health coverage ends, it may not mean your prescription drug
coverage was creditable. The notice must state that you had “creditable”
prescription drug coverage that expected to pay as much as Medicare’s
standard prescription drug plan pays.

o The following are not creditable prescription drug coverage: prescription drug
discount cards, free clinics, and drug discount websites.
o For additional information about creditable coverage, please look in your
Medicare & You 2015 Handbook or call Medicare at 1-800-MEDICARE (1-800633-4227). TTY users call 1-877-486-2048. You can call these numbers for free,
24 hours a day, 7 days a week.
•

If you were without creditable coverage, but you were without it for less than 63 days in a
row.

•

If you are receiving “Extra Help” from Medicare.

Section 10.4

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

If you disagree about your late enrollment penalty, you or your representative can ask for a
review of the decision about your late enrollment penalty. Generally, you must request this
review within 60 days from the date on the letter you receive stating you have to pay a late
enrollment penalty. Call Member Services to find out more about how to do this (phone numbers
are printed on the back cover of this booklet).
[Insert the following text if the plan disenrolls for failure to pay premiums: Important: Do not
stop paying your late enrollment penalty while you’re waiting for a review of the decision about
your late enrollment penalty. If you do, you could be disenrolled for failure to pay your plan
premiums.]

SECTION 11

Do you have to pay an extra Part D amount because
of your income?

Section 11.1

Who pays an extra Part D amount because of income?

Most people pay a standard monthly Part D premium. However, some people pay an extra
amount because of their yearly income. If your income is $[insert amount]or above for an

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

individual (or married individuals filing separately) or $[insert amount]or above for married
couples, you must pay an extra amount directly to the government for your Medicare Part D
coverage.
If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a
letter telling you what that extra amount will be and how to pay it. The extra amount will be
withheld from your Social Security, Railroad Retirement Board, or Office of Personnel
Management benefit check, no matter how you usually pay your plan premium, unless your
monthly benefit isn’t enough to cover the extra amount owed. If your benefit check isn’t enough
to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount
to the government. It cannot be paid with your monthly plan premium.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Section 11.2

How much is the extra Part D amount?

If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a
certain amount, you will pay an extra amount in addition to your monthly plan premium.
The chart below shows the extra amount based on your income.
If you filed an
individual tax
return and your
income in [insert
year] was:

Equal to or less
than $[insert
amount]

If you were
married but filed
a separate tax
return and your
income in [insert
year] was:

Equal to or less
than $[insert
amount]

If you filed a joint tax
return and your
income in [insert year]
was:

This is the monthly
cost of your extra
Part D This is the
monthly cost of your
extra Part D amount
(to be paid in
addition to your plan
premium)amount (to
be paid in addition to
your plan premium)

Equal to or less
than $[insert
amount]

Greater than
$[insert amount]and
less than or equal to
$[insert amount]

Greater than
$[insert
amount]and less
than or equal to
$[insert amount]

[insert amount]

Greater than
$[insert amount]and
less than or equal to
$[insert amount]

Greater than
$[insert
amount]and less
than or equal to
$[insert amount]

[insert amount]

Greater than
$[insert amount]and
less than or equal to
$[insert amount]

Greater than
$[insert
amount]and less
than or equal to
$[insert amount]

[insert amount]

Greater than
$[insert amount]

[insert amount]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
What you pay for your Part D prescription drugs

Section 11.3

What can you do if you disagree about paying an extra Part D
amount?

If you disagree about paying an extra amount because of your income, you can ask Social
Security to review the decision. To find out more about how to do this, contact Social Security at
1-800-772-1213 (TTY 1-800-325-0778).
Section 11.4

What happens if you do not pay the extra Part D amount?

The extra amount is paid directly to the government (not your Medicare plan) for your Medicare
Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of the costs for covered drugs

Chapter 5. Asking us to pay our share of the costs for covered drugs
SECTION 1
Section 1.1

Situations in which you should ask us to pay our share of
the cost of your covered drugs ....................................................... 85
If you pay our plan’s share of the cost of your covered drugs, you can ask
us for payment ............................................................................................... 85

SECTION 2
Section 2.1

How to ask us to pay you back ....................................................... 86
How and where to send us your request for payment ................................... 86

SECTION 3

We will consider your request for payment and say yes or
no ....................................................................................................... 87
We check to see whether we should cover the drug and how much we
owe ................................................................................................................ 87
If we tell you that we will not pay for all or part of the drug, you can
make an appeal .............................................................................................. 87

Section 3.1
Section 3.2

SECTION 4
Section 4.1

Other situations in which you should save your receipts
and send copies to us ...................................................................... 88
In some cases, you should send copies of your receipts to us to help us
track your out-of-pocket drug costs............................................................... 88

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of the costs for covered drugs

SECTION 1

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

Section 1.1

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

Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other
times, you may find that you have paid more than you expected under the coverage rules of the
plan. In either case, you can ask our plan to pay you back (paying you back is often called
“reimbursing” you).
Here are examples of situations in which you may need to ask our plan to pay you back. All of
these examples are types of coverage decisions (for more information about coverage decisions,
go to Chapter 7 of this booklet).
1. When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy and try to use your membership card to fill a
prescription, the pharmacy may not be able to submit the claim directly to us. When that
happens, you will have to pay the full cost of your prescription. (We cover prescriptions
filled at out-of-network pharmacies only in a few special situations. Please go to Chapter 3,
Section 2.5 to learn more.)
•

Save your receipt and send a copy to us when you ask us to pay you back for our share
of the cost.

2. When you pay the full cost for a prescription because you don’t have
your plan membership card with you
If you do not have your plan membership card with you, you can ask the pharmacy to call the
plan or look up your enrollment information. However, if the pharmacy cannot get the
enrollment information they need right away, 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 for our share
of the cost.

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

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of the costs for covered drugs

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 for our share of the cost.

4. If you are retroactively enrolled in our plan.
Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first
day of their enrollment has already passed. The enrollment date may even have occurred last
year.)
If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your
drugs after your enrollment date, you can ask us to pay you back for our share of the costs.
You will need to submit paperwork for us to handle the reimbursement.
•

Please call Member Services for additional information about how to ask us to pay you
back and deadlines for making your request. (Phone numbers for Member Services are
printed on the back cover of this booklet.)

[Plans should insert additional circumstances under which they will accept a paper claim from
an enrollee.]
All of the examples above are types of coverage decisions. This means that if we deny your
request for payment, you can appeal our decision. Chapter 7 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)) has information about
how to make an appeal.

SECTION 2

How to ask us to pay you back

Section 2.1

How and where to send us your request for payment

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

You don’t have to use the form, but it will help us process the information faster.

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of the costs for covered drugs

Mail your request for payment together with any receipts to us at this address:
[insert address]
[If the plan allows enrollees to submit oral payment requests, insert the following language:
You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look
for the section called, [plans may edit section title as necessary] Where to send a request that
asks us to pay for our share of the cost of a drug you have received.]
[Insert if applicable: You must submit your claim to us within [insert timeframe] of the date
you received the service, item, or drug.]
Contact Member Services if you have any questions (phone numbers are printed on the back
cover of this booklet). If you don’t know what you should have paid, 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

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

Section 3.1

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

When we receive your request for payment, we will let you know if we need any additional
information from you. Otherwise, we will consider your request and make a coverage decision.
•

If we decide that the drug is covered and you followed all the rules for getting the drug,
we will pay for our share of the cost. We will mail your reimbursement of our share of the
cost to you. (Chapter 3 explains the rules you need to follow for getting your Part D
prescription drugs covered.) We will send payment within 30 days after your request was
received.

•

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

Section 3.2

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

If you think we have made a mistake in turning down your request for payment or you don’t
agree with the amount we are paying, 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of the costs for covered drugs

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

SECTION 4

Other situations in which you should save your
receipts and send copies to us

Section 4.1

In some cases, you should send copies of your receipts to us
to help us track your out-of-pocket drug costs

There are some situations when you should let us know about payments you have made for your
drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your
payments so that we can calculate your out-of-pocket costs correctly. This may help you to
qualify for the Catastrophic Coverage Stage more quickly.
Here are two situations when you should send us copies of receipts to let us know about
payments you have made for your drugs:
1. When you buy the drug for a price that is lower than our price
[Plans with neither a coverage gap nor a deductible should delete this section.]
Sometimes when you are in the [insert if applicable: Deductible Stage OR Coverage Gap
Stage OR Deductible Stage and Coverage Gap Stage] you can buy your drug at a network
pharmacy for a price that is lower than our price.
•

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

•

Unless special conditions apply, you must use a network pharmacy in these situations
and your drug must be on our Drug List.

•

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

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Asking us to pay our share of the costs for covered drugs

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

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

•

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

Since you are not asking for payment in the two cases described above, these situations are not
considered coverage decisions. Therefore, you cannot make an appeal if you disagree with our
decision.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

Chapter 6. Your rights and responsibilities
SECTION 1
Section 1.1

Section 1.9

Our plan must honor your rights as a member of the plan .......... 91
[Plans may edit the section heading and content to reflect the types of
alternate format materials available to plan members. Plans may not edit
references to language except as noted below.] We must provide
information in a way that works for you (in languages other than English,
in Braille, in large print, or other alternate formats, etc.) .............................. 91
We must treat you with fairness and respect at all times .............................. 91
We must ensure that you get timely access to your covered drugs ............... 92
We must protect the privacy of your personal health information ................ 92
We must give you information about the plan, its network of pharmacies,
and your covered drugs ................................................................................. 93
We must support your right to make decisions about your care ................... 94
You have the right to make complaints and to ask us to reconsider
decisions we have made ................................................................................ 95
What can you do if you believe you are being treated unfairly or your
rights are not being respected? ...................................................................... 96
How to get more information about your rights ............................................ 96

SECTION 2
Section 2.1

You have some responsibilities as a member of the plan ............ 97
What are your responsibilities? ..................................................................... 97

Section 1.2
Section 1.3
Section 1.4
Section 1.5
Section 1.6
Section 1.7
Section 1.8

[Note: Plans may add to or revise this chapter as needed to reflect NCQA-required language.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

SECTION 1

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

Section 1.1

[Plans may edit the section heading and content to reflect the types
of alternate format materials available to plan members. Plans may
not edit references to language except as noted below.] We must
provide information in a way that works for you (in languages
other than English, in Braille, in large print, or other alternate
formats, etc.)

[Plans must insert a translation of Section 1.1 in all languages that meet the language
threshold.]
To get information from us in a way that works for you, please call Member Services (phone
numbers are printed on the back cover of this booklet).
Our plan has people and free language interpreter services available to answer questions from
non-English speaking members. [If applicable, plans may insert information about the
availability of written materials in languages other than English.] We can also give you
information in Braille, in large print, or other alternate formats if you need it. If you are eligible
for Medicare because of a 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 a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours
a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-4862048.
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, ethnicity, national origin, religion, gender, age, mental or
physical disability, health status, claims experience, medical history, genetic information,
evidence of insurability, or geographic location within the service area.
If you want more information or have concerns about discrimination or unfair treatment, please
call the Department of Health and Human Services’ Office for Civil Rights 1-800-368-1019
(TTY 1-800-537-7697) 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 printed on the back cover of this booklet). If you have a complaint, such as a
problem with wheelchair access, Member Services can help.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

Section 1.3

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

As a member of our plan, you have the right to get your prescriptions filled or refilled at any of
our network pharmacies without long delays. If you think that you are not getting your Part D
drugs within a reasonable amount of time, Chapter 7, Section 7 of this booklet tells what you can
do. (If we have denied coverage for your prescription drugs and you don’t agree with our
decision, Chapter 7, Section 4 tells what you can do.)
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 enrolled 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, called a
“Notice of Privacy Practice,” 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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

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 work
with your healthcare provider to 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 printed on the back cover of this booklet).
[Note: Plans may insert custom privacy practices.]
Section 1.5

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

[Plans may edit the section to reflect the types of alternate format materials available to plan
members and/or language primarily spoken in the plan service area.]
As a member of [insert 2015 plan name], 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 printed on the back 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 number of appeals made by
members and the plan’s performance ratings, including how it has been rated by plan
members and how it compares to other Medicare prescription drug plans.

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

•

Information about your coverage and the rules you must follow when using
your coverage.
o To get the details on your Part D prescription drug coverage, see Chapters 3 and 4
of this booklet plus the plan’s List of Covered Drugs (Formulary). These chapters,
together with the List of Covered Drugs (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 printed on the back cover of this booklet).

•

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

Section 1.6

We must support your right to make decisions about your care

You have the right to give instructions about what is to be done if you are not
able to make medical decisions for yourself
[Note: Plans that would like to provide members with state-specific information about advanced
directives, including contact information for the appropriate state agency, may do so.]
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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

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

Get the form. If you want to have an advance directive, you can get a form from your
lawyer, from a social worker, or from some office supply stores. You can sometimes get
advance directive forms from organizations that give people information about Medicare.
[Insert if applicable: You can also contact Member Services to ask for the forms (phone
numbers are printed on the back 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 did not follow
the instructions in it, you may file a complaint with [insert appropriate state-specific agency
(such as the State Department of Health)]. [Plans also have the option to include a separate
exhibit to list the state-specific agency in all states, or in all states in which the plan is filed, and
then should revise the previous sentence to make reference to that exhibit.]
Section 1.7

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

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

As explained in Chapter 7, what you need to do to follow up on a problem or concern depends on
the situation. You might need to ask our plan to make a coverage decision for you, make an
appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a
coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.
You have the right to get a summary of information about the appeals and complaints that other
members have filed against our plan in the past. To get this information, please call Member
Services (phone numbers are printed on the back cover of this booklet).
Section 1.8

What can you do if you believe 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 believe you have been treated unfairly or your rights have not been respected due to your
race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should
call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019
or TTY 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe 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 printed on the back cover of this
booklet).

•

You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.

•

Or, you can call 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 1.9

How to get more information about your rights

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

You can call Member Services (phone numbers are printed on the back cover of this
booklet).

•

You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.

•

You can contact Medicare.
o You can visit the Medicare website to read or download the publication “Your
Medicare Rights & Protections.” (The publication is available at:
http://www.medicare.gov/Pubs/pdf/11534.pdf .)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

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

SECTION 2

You have some responsibilities as a member of the
plan

Section 2.1

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 printed on the back cover of this booklet).
We’re here to help.
•

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

•

If you have any other prescription drug coverage in addition to our plan, you are
required to tell us. Please call Member Services to let us know (phone numbers are
printed on the back cover of this booklet).
o We are required to follow rules set by Medicare to make sure that you are using
all of your coverage in combination when you get your covered drugs from our
plan. This is called “coordination of benefits” because it involves coordinating
the drug benefits you get from our plan with any other drug benefits available to
you. We’ll help you coordinate your benefits. (For more information about
coordination of benefits, go to Chapter 1, Section 7.)

•

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

•

Help your doctors and other providers help you by giving them information, asking
questions, and following through on your care.
o To help your doctors and other health providers give you the best care, learn as
much as you are able to about your health problems and give them the
information they need about you and your health. Follow the treatment plans and
instructions that you and your doctors agree upon.
o Make sure your doctors know all of the drugs you are taking, including over-thecounter drugs, vitamins, and supplements.
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
Your rights and responsibilities

•

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 most of your drugs covered by the plan, you must pay your share of the cost
when you get the drug. This will be a [insert as appropriate: copayment (a fixed
amount) OR coinsurance (a percentage of the total cost)] Chapter 4 tells what you
must pay for your Part D prescription drugs.
o If you get any drugs that are not covered by our plan or by other insurance you
may have, you must pay the full cost.


If you disagree with our decision to deny coverage for a drug, you can
make an appeal. Please see Chapter 7 of this booklet for information about
how to make an appeal.

[Plans that do not disenroll members for non-payment may modify this section as
needed.]
o If you are required to pay a late enrollment penalty, you must pay the penalty to
remain a member of the plan.
o If you are required to pay the extra amount for Part D because of your yearly
income, you must pay the extra amount directly to the government to remain a
member of the plan.
•

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 printed on the back cover of this booklet).

•

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 printed on the back 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, you will have a Special Enrollment Period when you can join any Medicare
plan available in your new 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.
o If you move, it is also important to tell Social Security (or the Railroad
Retirement Board). You can find phone numbers and contact information for
these organizations in Chapter 2..

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•

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 printed on the back
cover of this booklet.
o For more information on how to reach us, including our mailing address, please
see Chapter 2.

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Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
BACKGROUND ......................................................................................................... 102
SECTION 1
Section 1.1
Section 1.2

Introduction .................................................................................... 102
What to do if you have a problem or concern ............................................. 102
What about the legal terms? ........................................................................ 102

SECTION 2

You can get help from government organizations that are
not connected with us.................................................................... 103
Where to get more information and personalized assistance ...................... 103

Section 2.1
SECTION 3
Section 3.1

To deal with your problem, which process should you use? ..... 103
Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints? ................................... 103

COVERAGE DECISIONS AND APPEALS ................................................................ 104
SECTION 4
Section 4.1
Section 4.2

A guide to the basics of coverage decisions and appeals ......... 104
Asking for coverage decisions and making appeals: the big picture .......... 104
How to get help when you are asking for a coverage decision or making
an appeal ...................................................................................................... 105

SECTION 5

Section 5.6

Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal ........................................................... 106
This section tells you 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 .............................. 106
What is an exception?.................................................................................. 108
Important things to know about asking for exceptions ............................... 110
Step-by-step: How to ask for a coverage decision, including an exception 111
Step-by-step: How to make a Level 1 Appeal (how to ask for a review of
a coverage decision made by our plan) ....................................................... 114
Step-by-step: How to make a Level 2 Appeal ............................................. 117

SECTION 6
Section 6.1

Taking your appeal to Level 3 and beyond .................................. 119
Levels of Appeal 3, 4, and 5 for Part D Drug Appeals ............................... 119

Section 5.1
Section 5.2
Section 5.3
Section 5.4
Section 5.5

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MAKING COMPLAINTS ............................................................................................. 120
SECTION 7
Section 7.1
Section 7.2
Section 7.3
Section 7.4
Section 7.5

How to make a complaint about quality of care, waiting
times, customer service, or other concerns ................................ 120
What kinds of problems are handled by the complaint process? ................ 120
The formal name for “making a complaint” is “filing a grievance” ........... 122
Step-by-step: Making a complaint .............................................................. 122
You can also make complaints about quality of care to the Quality
Improvement Organization.......................................................................... 123
You can also tell Medicare about your complaint ....................................... 123

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[Plans should ensure that the text or section heading immediately preceding each “Legal
Terms” box is kept on the same page as the box.]

BACKGROUND
SECTION 1

Introduction

Section 1.1

What to do if you have a problem or concern

This chapter explains two types of processes for handling problems and concerns:
•

For some types of problems, you need to use the process for coverage decisions and
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.
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 simpler words
in place of certain legal terms. For example, this chapter generally says “making a complaint”
rather than “filing a grievance,” “coverage decision” rather than “coverage determination,” and
“Independent Review Organization” instead of “Independent Review Entity.” It also uses
abbreviations as little as possible.
However, it can be helpful – and sometimes quite important – for you to know the correct legal
terms for the situation you are in. Knowing which terms to use will help you communicate more
clearly and accurately when you are dealing with your problem and get the right help or
information for your situation. To help you know which terms to use, we include legal terms
when we give the details for handling specific types of situations.

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SECTION 2

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

Section 2.1

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.
Get help from an independent government organization
We are always available to help you. But in some situations you may also want help or
guidance from someone who is not connected us. You can always contact your State Health
Insurance Assistance Program (SHIP). This government program has trained counselors in
every state. The program is not connected with us 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.
The services of SHIP counselors are free. [Plans providing SHIP contact information in an
exhibit may revise the following sentence to direct members to it] 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

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

Section 3.1

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, you only need to read the parts of this chapter that apply to
your situation. The guide that follows will help.

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To figure out which part of this chapter will help with your specific problem or concern,
START HERE
Is your problem or concern about your benefits or coverage?
(This includes problems about whether particular medical care or prescription drugs are
covered or not, the way in which they are covered, and problems related to payment for
medical care or prescription drugs.)
Yes. My problem is about benefits or coverage.
Go on to the next section of this chapter, Section 4, “A guide to the basics of
coverage decisions and appeals.”

No. My problem is not about benefits or coverage.
Skip ahead to Section 7 at the end of this chapter: “How to make a complaint
about quality of care, waiting times, customer service or other concerns.”

COVERAGE DECISIONS AND APPEALS
SECTION 4

A guide to the basics of coverage decisions and
appeals

Section 4.1

Asking for coverage decisions and making appeals: the big
picture

The process for coverage decisions and appeals deals with problems related to your benefits
and coverage for prescription drugs, including problems related to payment. This is the process
you use for issues such as whether a drug is covered or not and the way in which the drug is
covered.
Asking for coverage decisions
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your prescription drugs.

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We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay. In some cases we might decide a drug is not covered or is no longer covered
by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the
decision. An appeal is a formal way of asking us to review and change a coverage decision we
have made.
When you make an appeal, we review the coverage decision we have made to check to see if we
were following all of the rules properly. Your appeal is handled by different reviewers than those
who made the original unfavorable decision. 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 ask for a Level 2 Appeal. The Level 2
Appeal is conducted by an independent organization that is not connected to us. If you are not
satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional
levels of appeal.
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 printed on the back cover of
this booklet).

•

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).

•

Your doctor or other prescriber can make a request for you. For Part D prescription
drugs, your doctor or other prescriber can request a coverage decision or a Level 1 or
Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other
prescriber must be appointed as your representative.

•

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 prescriber, or other person to
be your representative, call Member Services (phone numbers are printed on the
back cover of this booklet) and ask for the “Appointment of Representative”
form. (The form is also available on Medicare’s website at

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http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf [plans may also
insert: or on our website at [insert website or link to form]].) The form gives that
person permission to act on your behalf. It must be signed by you and by the
person who you would like to act on your behalf. You must give us a copy of the
signed form.
•

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

SECTION 5

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

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.

Section 5.1

This section tells you 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 prescription drugs. Please
refer to our plan’s List of Covered Drugs (Formulary). To be covered, the drug must be used for
a medically accepted indication. (A “medically accepted indication” is a use of the drug that is
either approved by the Food and Drug Administration or supported by certain reference books.
See Chapter 3, Section 3 for more information about a medically accepted indication.)
•

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 (Formulary),
rules and restrictions on coverage, and cost information, see Chapter 3 (Using our plan’s
coverage for your Part D prescription drugs) and Chapter 4 (What you pay for your Part
D prescription drugs).

Part D coverage decisions and appeals
As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your
benefits and coverage or about the amount we will pay for your drugs.

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Legal Terms
An initial coverage decision about your
Part D drugs is called a “coverage
determination.”
Here are examples of coverage decisions you ask us to make about your Part D drugs:
•

You ask us to make an exception, including:
o Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs
(Formulary)
o Asking us to waive a restriction on the plan’s coverage for a drug (such as limits
on the amount of the drug you can get)
o [Plans with a formulary structure (e.g., no tiers) that does not allow for tiering
exceptions: omit this bullet] Asking to pay a lower cost-sharing amount for a
covered non-preferred drug

•

You ask us whether a drug is covered for you and whether you satisfy any applicable
coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs
(Formulary) but we require you to get approval from us before we will cover it for you.)
o Please note: If your pharmacy tells you that your prescription cannot be filled as
written, you will get a written notice explaining how to contact us to ask for a
coverage decision.

•

You ask us to pay for a prescription drug you already bought. This is a request for a
coverage decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

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This section tells you both how to ask for coverage decisions and how to request an appeal. Use
the chart below to help you determine which part has information for your situation:
Which of these situations are you in?
If you are in this situation:

This is what you can do:

Do you need a drug that isn’t on our Drug
List or need us to waive a rule or restriction
on a drug we cover?

You can ask us to make an exception. (This is a
type of coverage decision.)
Start with Section 5.2 of this chapter

Do you want us to cover a drug on our Drug
List and you believe you meet any plan
rules or restrictions (such as getting
approval in advance) for the drug you need?

You can ask us for a coverage decision.
Skip ahead to Section 5.4 of this chapter.

Do you want to ask us to pay you back for a
drug you have already received and paid
for?

You can ask us to pay you back. (This is a type
of coverage decision.)
Skip ahead to Section 5.4 of this chapter.

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

You can make an appeal. (This means you are
asking us to reconsider.)
Skip ahead to Section 5.5 of this chapter.

Section 5.2

What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an
“exception.” An exception is a type of coverage decision. Similar to 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, your doctor or other prescriber will need to explain the medical
reasons why you need the exception approved. We will then consider your request. Here are
[insert as applicable: two OR three] examples of exceptions that you or your doctor or other
prescriber can ask us to make:

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1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary).
(We call it the “Drug List” for short.)
Legal Terms
Asking for coverage of a drug that is not on
the Drug List is sometimes called asking
for a “formulary exception.”
•

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

2. Removing a restriction on our coverage for a covered drug. There are extra rules or
restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more
information, go to Chapter 3).
Legal Terms
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:
o [Omit if plan does not use generic substitution] Being required to use the
generic version of a drug instead of the brand name drug.
o [Omit if plan does not use prior authorization] Getting plan approval in
advance before we will agree to cover the drug for you. (This is sometimes
called “prior authorization.”)
o [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.”)
o [Omit if plan does not use quantity limits] Quantity limits. For some drugs,
there are restrictions on the amount of the drug you can have.

•

If we agree to make an exception and waive a restriction for you, you can ask for an
exception to the copayment or coinsurance amount we require you to pay for the
drug.

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3. [Plans with a formulary structure (e.g., no tiers) that does not allow for tiering
exceptions: omit this section] Changing coverage of a drug to a lower cost-sharing
tier. Every drug on our Drug List is in one of [insert number of tiers] cost-sharing tiers.
In general, the lower the cost-sharing tier number, the less you will pay as your share of
the cost of the drug.
Legal Terms
Asking to pay a lower price for a covered
non-preferred drug is sometimes called
asking for a “tiering exception.”
•

If your drug is in [insert name of non-preferred/highest cost-sharing tier 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 /lowest cost-sharing tier subject to the tiering
exceptions process]. This would lower your share of the cost for the drug.

•

[Plans with more than one tier subject to the tiering exceptions process may repeat
the bullet above for each tier.]

•

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

Section 5.3

Important things to know about asking for exceptions

Your doctor must tell us the medical reasons
Your doctor or other prescriber must give us a statement that explains the medical reasons for
requesting an exception. For a faster decision, include this medical information from your doctor
or other prescriber when you ask for the exception.
Typically, our Drug List includes more than one drug for treating a particular condition. These
different possibilities are called “alternative” drugs. If an alternative drug would be just as
effective as the drug you are requesting and would not cause more side effects or other health
problems, we will generally not approve your request for an exception.
We can say yes or no to your request
•

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

•

If we say no to your request for an exception, you can ask for a review of our decision by
making an appeal. Section 5.5 tells you how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.

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111

Step-by-step: How to ask for a coverage decision, including an
exception

Step 1: You ask us to make a coverage decision about the drug(s) or payment
you need. If your health requires a quick response, you must ask us to make a
“fast coverage decision.” You cannot ask for a fast coverage decision if you are
asking us to pay you back for a drug you already bought.
What to do
•

Request the type of coverage decision you want. Start by calling, writing, or
faxing us to make your request. You, your representative, or your doctor (or other
prescriber) can do this. You can also access the coverage decision process through
our website. For the details, go to Chapter 2, Section 1 and look for the section
called, [plans may edit section title as necessary] How to contact us when you are
asking for a coverage decision about your Part D prescription drugs. Or if you are
asking us to pay you back for a drug, go to the section called, [plans may edit
section title as necessary] Where to send a request that asks us to pay for our
share of the cost for a drug you have received.

•

You or your doctor or someone else who is acting on your behalf can ask for a
coverage decision. 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.

•

If you want to ask us to pay you back for a drug, start by reading Chapter 5 of
this booklet: Asking us to pay our share of the costs for covered drugs. Chapter 5
describes the situations in which you may need to ask for reimbursement. It also
tells how to send us the paperwork that asks us to pay you back for our share of the
cost of a drug you have paid for.

•

If you are requesting an exception, provide the “supporting statement.” Your
doctor or other prescriber must give us the medical reasons for the drug exception
you are requesting. (We call this the “supporting statement.”) Your doctor or other
prescriber can fax or mail the statement to us. Or your doctor or other prescriber
can tell us on the phone and follow up by faxing or mailing a written statement if
necessary. See Sections 5.2 and 5.3 for more information about exception requests.

•

We must accept any written request, including a request submitted on the CMS
Model Coverage Determination Request Form [insert if applicable: or on our
plan’s form], which [insert if applicable: is OR are] available on our website.

•

[Plans that allow enrollees to submit coverage determination requests
electronically through, for example, a secure member portal may include a brief
description of that process.]

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

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

•

To get a fast coverage decision, you must meet two requirements:
o You can get a fast coverage decision only if you are asking for a drug you have
not yet received. (You cannot get a fast coverage decision if you are asking us to
pay you back for a drug you have already bought.)
o You can get a fast coverage decision only if using the standard deadlines could
cause serious harm to your health or hurt your ability to function.

•

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

•

If you ask for a fast coverage decision on your own (without your doctor’s or other
prescriber’s support), we will decide whether your health requires that we give you a
fast coverage decision.
o If we decide that your medical condition does not meet the requirements for a
fast coverage decision, we will send you a letter that says so (and we will use
the standard deadlines instead).
o This letter will tell you that if your doctor or other prescriber asks for the fast
coverage decision, we will automatically give a fast coverage decision.
o The letter will also tell how you can file a complaint about our decision to give
you a standard coverage decision instead of the fast coverage 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 information about the process for making complaints, see Section 7 of
this chapter.)

Step 2: We consider your request and we give you our answer.
Deadlines for a “fast” coverage decision
•

If we are using the fast deadlines, we must give you our answer within 24
hours.

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o Generally, this means within 24 hours after we receive your request. If you are
requesting an exception, we will give you our answer 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 talk about this review organization and
explain what happens at Appeal Level 2.
•

If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 24 hours after we receive your request or
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. We will also tell you how to appeal.

Deadlines for a “standard” coverage decision about a drug you have not yet received
•

If we are using the standard deadlines, we must give you our answer within 72
hours.
o Generally, this means within 72 hours after we receive your request. If you are
requesting an exception, we will give you our answer within 72 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
organization. Later in this section, we talk about this review organization and
explain what happens at Appeal Level 2.

•

If our answer is yes to part or all of what you requested –
o If we approve your request for coverage, we must provide the coverage we
have agreed to provide within 72 hours after we receive your request or
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. We will also tell you how to appeal.

Deadlines for a “standard” coverage decision about payment for a drug you have already
bought
•

We must give you our answer within 14 calendar days after we receive your request.
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 organization.
Later in this section, we talk about this review organization and explain what
happens at Appeal Level 2.

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•

If our answer is yes to part or all of what you requested, we are also required to make
payment to you within 14 calendar days after we receive 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. We will also tell you how to appeal.

Step 3: If we say no to your coverage request, you decide if you want to make an
appeal.
•

If we say no, you have the right to request an appeal. Requesting an appeal means
asking us to reconsider – and possibly change – the decision we made.

Section 5.5

Step-by-step: How to make a Level 1 Appeal
(how to ask for a review of a coverage decision made by our plan)
Legal Terms
An appeal to the plan about a Part D drug
coverage decision is called a plan
“redetermination.”

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

•

If you are asking for a standard appeal, make your appeal by submitting a
written 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 [plans may edit section title as necessary] (How to contact
our plan when you are making an appeal about your Part D prescription drugs).]

•

If you are asking for a fast appeal, you may make your appeal in writing or
you may call us at the phone number shown in Chapter 2, Section 1 [plans
may edit section title as necessary] (How to contact our plan when you are making
an appeal about your part D prescription drugs).

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•

We must accept any written request, including a request submitted on the CMS
Model Coverage Determination Request Form, which is available on our website.

•

[Plans that allow enrollees to submit appeal requests electronically through, for
example, a secure member portal may include a brief description of that process.]

•

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. Examples of good cause for missing the
deadline may include if you had a serious illness that prevented you from
contacting us or if we provided you with incorrect or incomplete information about
the deadline for requesting an appeal.

•

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

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

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

•

The requirements for getting a “fast appeal” are the same as those for getting a
“fast coverage decision” in Section 5.4 of this chapter.

Step 2: We consider your appeal and we give you our answer.
•

When we are reviewing your appeal, we take another careful look at all of the
information about your coverage request. We check to see if we were following all the
rules when we said no to your request. We may contact you or your doctor or other
prescriber to get more information.

Deadlines for a “fast” appeal
•

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.

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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 Review Organization. (Later in this section, we talk about this
review 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 after we receive your appeal.

•

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

Deadlines for a “standard” appeal
•

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. If
you believe your health requires it, you should ask for “fast” appeal.
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 Review Organization. Later in this section, we tell about this
review 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 –
o If we approve a request for coverage, 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.
o If we approve a request to pay you back for a drug you already bought, we are
required to send payment to you within 30 calendar days after we receive
your appeal 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 and how to appeal our decision.

Step 3: If we say no to your appeal, you decide if you want to continue with the
appeals process and make another appeal.
•
•

If we say 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).

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

If we say 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 we made when we said no to your first appeal. This
organization decides whether the decision we made should be changed.
Legal Terms
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 (or your representative or your doctor or
other prescriber) must contact the Independent Review Organization and ask for
a review of your case.
•

If we say no to your Level 1 Appeal, the written notice we send you will include
instructions on how to make a Level 2 Appeal with the Independent Review
Organization. These instructions will tell who can make this Level 2 Appeal, what
deadlines you must follow, and how to reach the review organization.

•

When you make an appeal to the Independent Review Organization, we will send the
information we have 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.]

•

You have a right to give the Independent Review Organization additional information
to support your appeal.

Step 2: The Independent Review Organization does a review of your appeal and
gives you an answer.
•

The Independent Review Organization is an independent organization that is
hired by Medicare. This organization is not connected with us and it is not a
government agency. This organization is a company chosen by Medicare to review
our decisions about your Part D benefits with us.

•

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.

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Deadlines for “fast appeal” at Level 2
•

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 after it receives
your appeal request.

•

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.

Deadlines for “standard appeal” at Level 2
•

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 after it receives your appeal.

•

If the Independent Review Organization says yes to part or all of what you
requested –
o If the Independent Review Organization approves a request for coverage, 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.
o If the Independent Review Organization approves a request to pay you back for
a drug you already bought, we are required to send payment to you within 30
calendar days 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 the organization agrees with our decision not
to approve your request. (This is called “upholding the decision.” It is also called “turning down
your appeal.”)
To continue and make another appeal at Level 3, the dollar value of the drug coverage you are
requesting must meet a minimum amount. If the dollar value of the coverage you are requesting
is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you
get from the Independent Review Organization will tell you the dollar value that must be in
dispute to continue with the appeals process.
Step 3: If the dollar value of the coverage you are requesting meets the
requirement, 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).

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•

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.

•

The Level 3 Appeal is handled by an administrative law judge. Section 6 in this
chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 6

Taking your appeal to Level 3 and beyond

Section 6.1

Levels of Appeal 3, 4, and 5 for Part D Drug Appeals

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 value of the drug you have appealed meets a certain dollar amount, you may be able to go
on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. 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.
Level 3 Appeal

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. We must authorize or provide the drug coverage that was approved by
the Administrative Law Judge within 72 hours (24 hours for expedited appeals) or
make payment no later than 30 calendar days after we receive the decision.

•

If the Administrative Law Judge says no to your appeal, the appeals process may or
may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you can continue to the next level of the
review process. If the administrative law judge says no to your appeal, the notice
you get will tell you what to do next if you choose to continue with your appeal.

Level 4 Appeal

The Appeals Council will review your appeal and give you an answer. The
Appeals Council works for the Federal government.

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•

If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was approved by
the Appeals Council within 72 hours (24 hours for expedited appeals) or make
payment no later than 30 calendar days after we receive the decision.

•

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. If the Appeals Council says no to your appeal or denies
your request to review the appeal, the notice you get will tell you whether the rules
allow you to go on to a Level 5 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.

Level 5 Appeal
•

A judge at the Federal District Court will review your appeal.

This is the last step of the appeals process.

MAKING COMPLAINTS
SECTION 7

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.

Section 7.1

What kinds of problems are handled by the complaint
process?

This section explains how to use the process for making complaints. The complaint process is
used for certain types of problems only. This includes problems related to quality of care, waiting
times, and the customer service you receive. Here are examples of the kinds of problems handled
by the complaint process.

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If you have any of these kinds of problems, you can “make a complaint”
Complaint

Example

Quality of your
medical care

•

Are you unhappy with the quality of the care you have received?

Respecting your
privacy

•

Do you believe that someone did not respect your right to privacy or
shared information about you that you feel should be confidential?

Disrespect, poor
customer service,
or other negative
behaviors

•
•
•

Has someone been rude or disrespectful to you?
Are you unhappy with how our Member Services has treated you?
Do you feel you are being encouraged to leave the plan?

Waiting times

•

Have you been kept waiting too long by pharmacists? Or by our
Member Services or other staff at the plan?
o Examples include waiting too long on the phone or when getting
a prescription.

Cleanliness

•

Are you unhappy with the cleanliness or condition of a pharmacy?

Information you
get from us

•

Do you believe we have not given you a notice that we are required
to give?
Do you think written information we have given you is hard to
understand?

•
Timeliness
(These types of
complaints are all
related to the
timeliness of our
actions related to
coverage decisions
and appeals)

The process of asking for a coverage decision and making appeals is
explained in sections 4-6 of this chapter. If you are asking for a decision
or making an appeal, you use that process, not the complaint process.
However, if you have already asked us for a coverage decision or made
an appeal, and you think that we are not responding quickly enough, you
can also make a complaint about our slowness. Here are examples:
•
•
•

•

If you have asked us to give you a “fast coverage decision” or a “fast
appeal,” and we have said we will not, you can make a complaint.
If you believe we are not meeting the deadlines for giving you a
coverage decision or an answer to an appeal you have made, you
can make a complaint.
When a coverage decision we made is reviewed and we are told that
we must cover or reimburse you for certain drugs, there are
deadlines that apply. If you think we are not meeting these
deadlines, you can make a complaint.
When we do not give you a decision on time, we are required to
forward your case to the Independent Review Organization. If we do
not do that within the required deadline, you can make a complaint.

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The formal name for “making a complaint” is “filing a
grievance”
Legal Terms
•

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.”
Section 7.3

Step-by-step: Making a complaint

Step 1: Contact us promptly – either by phone or in writing.
•

Usually, calling Member Services is the first step. If there is anything else you need to
do, Member Services will let you know. [Insert phone number, TTY, and days 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 put your complaint in writing, we will
respond to your complaint in writing.

•

[Insert description of the procedures (including time frames) and instructions about what
members need to do if they want to use the 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 calendar days after you had the problem you want to
complain about.

•

If you are making a complaint because we denied your request for a “fast coverage
decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you
have a “fast” complaint, it means we will give you an answer within 24 hours.
Legal Terms
What this section calls a “fast complaint”
is also called an “expedited grievance.”

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Step 2: We look into your complaint and give you our answer.
•

If possible, we will answer you right away. If you call us with a complaint, we may be
able to give you an answer on the same phone call. If your health condition requires us to
answer quickly, we will do that.

•

Most complaints are answered in 30 calendar 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
calendar days (44 calendar 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. Our response will include our
reasons for this answer. We must respond whether we agree with the complaint or not.

Section 7.4

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

You can make your complaint about the quality of care you received to us by using the step-bystep 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 us).
o The Quality Improvement Organization is a group of practicing doctors and
other health care experts paid by the Federal government to check and improve
the care given to Medicare patients.
o To find the name, address, and phone number of the Quality Improvement
Organization for your state, look in Chapter 2, Section 4, of this booklet. If you
make a complaint to this organization, we will work 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 us and also to the Quality Improvement
Organization.

Section 7.5

You can also tell Medicare about your complaint

You can submit a complaint about [insert 2015 plan name] directly to Medicare. To submit a
complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare

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takes your complaints seriously and will use this information to help improve the quality of the
Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your issue,
please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

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Chapter 8. Ending your membership in the plan
SECTION 1
Section 1.1

Introduction .................................................................................... 126
This chapter focuses on ending your membership in our plan .................... 126

SECTION 2
Section 2.1

When can you end your membership in our plan? ..................... 126
Usually, you can end your membership during the Annual Enrollment
Period........................................................................................................... 126
In certain situations, you can end your membership during a Special
Enrollment Period........................................................................................ 127
Where can you get more information about when you can end your
membership? ............................................................................................... 129

Section 2.2
Section 2.3

SECTION 3
Section 3.1

How do you end your membership in our plan? ......................... 129
Usually, you end your membership by enrolling in another plan ............... 129

SECTION 4

Until your membership ends, you must keep getting your
drugs through our plan .................................................................. 131
Until your membership ends, you are still a member of our plan ............... 131

Section 4.1
SECTION 5
Section 5.1
Section 5.2
Section 5.3

[Insert 2015 plan name] must end your membership in the
plan in certain situations ............................................................... 131
When must we end your membership in the plan? ..................................... 131
We cannot ask you to leave our plan for any reason related to your health 133
You have the right to make a complaint if we end your membership in
our plan ........................................................................................................ 133

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SECTION 1

Introduction

Section 1.1

This chapter focuses on ending your membership in our plan

Ending your membership in [insert 2015 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
voluntarily end your membership in the plan. Section 2 tells you when you can
end your membership in the plan.
o The process for voluntarily 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 you do not choose to leave, but we are required to
end your membership. Section 5 tells you about situations when we must end your
membership.

If you are leaving our plan, you must continue to get your Part D prescription drugs through our
plan until your membership ends.

SECTION 2

When can you end your membership in our plan?

You may end your membership in our plan only during certain times of the year, known as
enrollment periods. All members have the opportunity to leave the plan during the Annual
Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times
of the year.
Section 2.1

Usually, you can end your membership during the Annual
Enrollment Period

You can end your membership during the Annual Enrollment Period (also known as the
“Annual Coordinated Election Period”). This is the time when you should review your health
and drug coverage and make a decision about your coverage for the upcoming year.
•

When is the Annual Enrollment Period? This happens from October 15 to
December 7.

•

What type of plan can you switch to during the Annual Enrollment Period?
During this time, you can review your health coverage and your prescription drug

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coverage. You can choose to keep your current coverage or make changes to your
coverage for the upcoming year. If you decide to change to a new plan, you can
choose any of the following types of plans:
o Another Medicare prescription drug plan.
o Original Medicare without a separate Medicare prescription drug plan.


If you receive “Extra Help” from Medicare to pay for your
prescription drugs: If you do not enroll in a separate Medicare
prescription drug plan, Medicare may enroll you in a drug plan, unless
you have opted out of automatic enrollment.

o – or – A Medicare health plan. A Medicare health plan is a plan offered by a
private company that contracts with Medicare to provide all of the Medicare
Part A (Hospital) and Part B (Medical) benefits. Some Medicare health plans
also include Part D prescription drug coverage.
•

If you enroll in most Medicare health plans, you will be disenrolled
from [insert 2015 plan name] when your new plan’s coverage begins.
However, if you choose a Private Fee-for-Service plan without Part D
drug coverage, a Medicare Medical Savings Account plan, or a
Medicare Cost Plan, you can enroll in that plan and keep [insert 2015
plan name] for your drug coverage. If you do not want to keep our
plan, you can choose to enroll in another Medicare prescription drug
plan or drop Medicare prescription drug coverage.

Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage, you may need to pay a late enrollment
penalty if you join a Medicare drug plan later. (“Creditable” coverage means the
coverage is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage.) [insert if applicable: See Chapter 4, Section 10 for
more information about the late enrollment penalty.]
•

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

Section 2.2

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

In certain situations, members of [insert 2015 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
Medicare, or visit the Medicare website (http://www.medicare.gov):
o If you have moved out of your plan’s service area.

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o [Revise bullet to use state-specific name, if applicable] If you have Medicaid.
o If you are eligible for “Extra Help” with paying for your Medicare
prescriptions.
o If we violate our contract with you.
o If you are getting care in an institution, such as a nursing home or long-term
care (LTC) hospital.
o [Plans in states with PACE, insert: If you enroll in the Program of Allinclusive Care for the Elderly (PACE). [National or multi-state plans when
there is variability in the availability of PACE insert: PACE is not available in
all states. If you would like to know if PACE is available in your state, please
contact Member Services (phone numbers are printed on the back cover of
this booklet).]
•

When are Special Enrollment Periods? The enrollment periods vary depending on
your situation.

•

What can you do? To find out if you are eligible for a Special Enrollment Period,
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. If you are eligible to end your membership
because of a special situation, you can choose to change both your Medicare health
coverage and prescription drug coverage. This means you can choose any of the
following types of plans:
o Another Medicare prescription drug plan.
o Original Medicare without a separate Medicare prescription drug plan.


If you receive “Extra Help” from Medicare to pay for your
prescription drugs: If you switch to Original Medicare and do not
enroll in a separate Medicare prescription drug plan, Medicare may
enroll you in a drug plan, unless you have opted out of automatic
enrollment.

If you enroll in most Medicare health plans, you will automatically be
disenrolled from [insert 2015 plan name] when your new plan’s
coverage begins. However, if you choose a Private Fee-for-Service
plan without Part D drug coverage, a Medicare Medical Savings
Account plan, or a Medicare Cost Plan, you can enroll in that plan and
keep [insert 2015 plan name] for your drug coverage. If you do not
want to keep our plan, you can choose to enroll in another Medicare
prescription drug plan or to drop Medicare prescription drug coverage.

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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.

Section 2.3

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 printed on the back cover of this
booklet).

•

You can find the information in the Medicare & You 2015 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 the Medicare website
(http://www.medicare.gov). Or, you can order a printed copy by calling Medicare
at the number below.

•

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

SECTION 3

How do you end your membership in our plan?

Section 3.1

Usually, you end your membership by enrolling in another
plan

Usually, to end your membership in our plan, you simply enroll in another Medicare plan during
one of the enrollment periods (see Section 2 in this chapter for information about the enrollment
periods). However, there are two situations in which you will need to end your membership in a
different way:
•

If you want to switch from our plan to Original Medicare without a Medicare prescription
drug plan, you must ask to be disenrolled from our plan.

•

If you join a Private Fee-for-Service plan without prescription drug coverage, a Medicare
Medical Savings Account Plan, or a Medicare Cost Plan, enrollment in the new plan will
not end your membership in our plan. In this case, you can enroll in that plan and keep

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[insert 2015 plan name] for your drug coverage. If you do not want to keep our plan, you
can choose to enroll in another Medicare prescription drug plan or ask to be disenrolled
from our plan.
If you are in one of these two situations and want to leave our plan, there are two ways you can
ask to be disenrolled:
•

You can make a request in writing to us. Contact Member Services if you need more
information on how to do this (phone numbers are printed on the back cover of this
booklet).

•

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

Note: If you disenroll from Medicare prescription drug coverage and go without creditable
prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare
drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at
least as much as Medicare’s standard prescription drug coverage.) See Chapter 4, Section 10 for
more information about the late enrollment penalty.
The table below explains how you should end your membership in our plan.
If you would like to switch
from our plan to:

This is what you should do:

•

Another Medicare prescription
drug plan.

•

A Medicare health plan.

•

Enroll in the new Medicare prescription drug plan.
You will automatically be disenrolled from [insert 2015 plan
name] when your new plan’s coverage begins.
Enroll in the Medicare health plan. With most Medicare
health plans, you will automatically be disenrolled from
[insert 2015 plan name] when your new plan’s coverage
begins.
However, if you choose a Private Fee-For-Service plan
without Part D drug coverage, a Medicare Medical Savings
Account plan, or a Medicare Cost Plan, you can enroll in that
new plan and keep [insert 2015 plan name] for your drug
coverage. If you want to leave our plan, you must either
enroll in another Medicare prescription drug plan or ask to
be disenrolled. To ask to be disenrolled, you must send us a
written request (contact Member Services (phone numbers
are printed on the back cover of this booklet) if you need
more information on how to do this) or contact Medicare at
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days
a week (TTY users should call 1-877-486-2048).

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If you would like to switch
from our plan to:

This is what you should do:

•

Send us a written request to disenroll. Contact Member
Services if you need more information on how to do this
(phone numbers are printed on the back cover of this
booklet).

•

You can also contact Medicare at 1-800-MEDICARE (1-800633-4227), 24 hours a day, 7 days a week, and ask to be
disenrolled. TTY users should call 1-877-486-2048.

Original Medicare without a
separate Medicare prescription
drug plan.

Note: If you disenroll from a
Medicare prescription drug plan
and go without creditable
prescription drug coverage, you
may need to pay a late enrollment
penalty if you join a Medicare drug
plan later. See Chapter 4, Section
10 for more information about the
late enrollment penalty.

SECTION 4

Until your membership ends, you must keep getting
your drugs through our plan

Section 4.1

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

If you leave [insert 2015 plan name], it may take time before your membership ends and your
new Medicare coverage goes into effect. (See Section 2 for information on when your new
coverage begins.) During this time, you must continue to get your prescription drugs through our
plan.
•

You should continue to use our network pharmacies to get your prescriptions filled
until your membership in our plan ends. Usually, your prescription drugs are only
covered if they are filled at a network pharmacy [insert if applicable: including through
our mail-order pharmacy services.]

SECTION 5

[Insert 2015 plan name] must end your membership in
the plan in certain situations

Section 5.1

When must we end your membership in the plan?

[Insert 2015 plan name] must end your membership in the plan if any of the following
happen:
•

If you do not stay continuously enrolled in Medicare Part A or Part B (or both).

•

If you move out of our service area.

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If you are away from our service area for more than 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. (Phone numbers for
Member Services are printed on the back cover of this booklet.)

•

If you become incarcerated (go to prison).

•

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. (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 continuously behave in a way that is
disruptive and makes it difficult for us to provide care for you and other members of our
plan. (We cannot make you leave our plan for this reason unless we get permission from
Medicare first.)

•

[Omit bullet and sub-bullet if not applicable] If you let someone else use your
membership card to get prescription drugs. (We cannot make you leave our plan for this
reason unless we get permission from Medicare first.)
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. Plans with different disenrollment policies
for dual eligible members and/or members with LIS who do not pay plan premiums must
edit these bullets as necessary to reflect their policies. Plans with different disenrollment
policies must be very clear as to which population is excluded from the policy to disenroll
for failure to pay plan premiums.] If you do not pay the plan premiums for [insert length
of grace period, which cannot be less than 2 calendar months].
o We must notify you in writing that you have [insert length of grace period, which
cannot be less than 2 calendar months] to pay the plan premium before we end
your membership.

•

If you are required to pay the extra Part D amount because of your income and you do not
pay it, Medicare will disenroll you from our plan and you will lose prescription drug
coverage.

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 printed on the
back cover of this booklet).

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133

We cannot ask you to leave our plan for any reason related to
your health

[Insert 2015 plan name] is not allowed to 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.
Section 5.3

You have the right to make a complaint if we end your
membership in our plan

If we end your membership in our plan, we must tell you our reasons in writing for ending your
membership. We must also explain how you can make a complaint about our decision to end
your membership. You can also look in Chapter 7, Section 7 for information about how to make
a complaint.

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Legal notices

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Chapter 9. Legal notices
SECTION 1

Notice about governing law ........................................................... 135

SECTION 2

Notice about non-discrimination................................................... 135

SECTION 3

Notice about Medicare Secondary Payer subrogation rights ..... 135

[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.]

2015 Evidence of Coverage for [insert 2015 plan name]
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Legal notices

SECTION 1

135

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 non-discrimination

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 prescription drug 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.

SECTION 3

Notice about Medicare Secondary Payer subrogation
rights

We have the right and responsibility to collect for covered Medicare prescription drugs for which
Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108
and 423.462, [insert 2015 plan name], as a Medicare prescription drug plan sponsor, will
exercise the same rights of recovery that the Secretary exercises under CMS regulations in
subparts B through D of part 411 of 42 CFR and the rules established in this section supersede
any State laws.
[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.]

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Chapter 10. Definitions of important words
[Plans should insert definitions as appropriate to the plan type described in the EOC. You may
insert definitions not included in this model and exclude model definitions not applicable to your
plan, or to your contractual obligations with CMS or enrolled Medicare beneficiaries.]
[If allowable revisions to terminology (e.g., changing “Member Services” to “Customer
Service”) affect glossary terms, plans should re-label the term and alphabetize it within the
glossary.]
Appeal – An appeal is something you do if you disagree with our decision to deny a request for
coverage of prescription drugs or payment for drugs you already received. For example, you may
ask for an appeal if we don’t pay for a drug you think you should be able to receive. Chapter 7
explains appeals, including the process involved in making an appeal.
Annual Enrollment Period – A set time each fall when members can change their health or
drugs plans or switch to Original Medicare. The Annual Enrollment Period is from October 15
until December 7.
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 2015 out-of-pocket threshold] in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers
Medicare. Chapter 2 explains how to contact CMS.
Coinsurance – An amount you may be required to pay as your share of the cost for prescription
drugs [insert if applicable: after you pay any deductibles]. Coinsurance is usually a percentage
(for example, 20%).
Copayment – An amount you may be required to pay as your share of the cost for a prescription
drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay
$10 or $20 for a prescription drug.
Cost-sharing – Cost-sharing refers to amounts that a member has to pay when drugs are
received. [Insert if plan has a premium: (This is in addition to the plan’s monthly premium.)]
Cost-sharing includes any combination of the following three types of payments: (1) any
deductible amount a plan may impose before drugs are covered; (2) any fixed “copayment”
amount that a plan requires when a specific drug is received; or (3) any “coinsurance” amount, a
percentage of the total amount paid for a drug, that a plan requires when a specific drug is

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received. A “daily cost-sharing rate” may apply when your doctor prescribes less than a full
month’s supply of certain drugs for you and you are required to pay a copay.
[Delete if plan does not use tiers] Cost-Sharing Tier – Every drug on the list of covered drugs is
in one of [insert number of tiers] cost-sharing tiers. In general, the higher the cost-sharing tier,
the higher your cost for the drug.
Coverage Determination – A decision 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. Coverage determinations are called “coverage
decisions” in this booklet. Chapter 7 explains how to ask us for a coverage decision.
Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to 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.
Daily cost-sharing rate – A “daily cost-sharing rate” may apply when your doctor prescribes
less than a full month’s supply of certain drugs for you and you are required to pay a copay. A
daily cost-sharing rate is the copay divided by the number of days in a month’s supply. Here is
an example: If your copay for a one-month supply of a drug is $30, and a one-month’s supply in
your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. This means you pay $1 for
each day’s supply when you fill your prescription.
Deductible – The amount you must pay for prescriptions before our plan begins to pay.
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).
Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of
filling a prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare
and package the prescription.
Emergency – A medical emergency is when you, or any other prudent layperson with an
average knowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injury, severe pain, or a medical condition that is
quickly getting worse.
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

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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 a
lower 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).
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.
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, a “generic”
drug works the same as a brand name drug and usually costs less.
Grievance – A type of complaint you make about us or one of our network pharmacies,
including a complaint concerning the quality of your care. This type of complaint does not
involve coverage or payment disputes.
Income Related Monthly Adjustment Amount (IRMAA) – If your income is above a certain
limit, you will pay an income-related monthly adjustment amount in addition to your plan
premium. For example, individuals with income greater than $[insert amount] and married
couples with income greater than $[insert amount] must pay a higher Medicare Part B (medical
insurance) and Medicare prescription drug coverage premium amount. This additional amount is
called the income-related monthly adjustment amount. Less than 5% of people with Medicare are
affected, so most people will not pay a higher premium.
Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage.
Initial Coverage Stage – This is the stage before your [insert as applicable: total drug costs
including amounts you have paid and what your plan has paid on your behalf OR out-of-pocket
costs] for the year have reached [insert as applicable: [insert 2015 initial coverage limit] OR
[insert 2015 out-of-pocket threshold]].
Initial Enrollment Period – When you are first eligible for Medicare, the period of time when
you can sign up for Medicare Part A and Part B. For example, if you’re eligible for Medicare
when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months
before the month you turn 65, includes the month you turn 65, and ends 3 months after the month
you turn 65.
Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug
coverage if you go without creditable coverage (coverage that is expected 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. For example, if you receive “Extra Help” from Medicare to pay your

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prescription drug plan costs, the late enrollment penalty rules do not apply to you. If you receive
“Extra Help,” you do not pay a late enrollment penalty.
List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered 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.
Low Income Subsidy (LIS) – See “Extra Help.”
Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical
costs for some people with low incomes and limited resources. Medicaid programs vary from
state to state, but most health care costs are covered if you qualify for both Medicare and
Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.
Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug
Administration or supported by certain reference books. See Chapter 3, Section 3 for more
information about a medically accepted indication.
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). People
with Medicare can get their Medicare health coverage through Original Medicare [insert only if
there is a cost plan in your service area: , a Medicare Cost Plan,] [insert only if there is a PACE
plan in your state: a PACE plan,] or a Medicare Advantage Plan.
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 and
Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service
(PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. If you are enrolled in a
Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for
under Original Medicare. 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 – A Medicare Cost Plan is 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 Coverage Gap Discount Program – A program that provides discounts on most
covered Part D brand name drugs to Part D enrollees who have reached the Coverage Gap Stage
and who are not already receiving “Extra Help.” Discounts are based on agreements between the
Federal government and certain drug manufacturers. For this reason, most, but not all, brand
name drugs are discounted.

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Medicare-Covered Services – Services covered by Medicare Part A and Part B.
Medicare Health Plan – A Medicare health plan is offered by a private company that contracts
with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the
plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans,
Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).
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).
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.
Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare
is offered by the government, and not a private health plan like Medicare Advantage Plans and
prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care providers payment amounts established by Congress.
You can see any doctor, hospital, or other health care provider that accepts Medicare. You must
pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your
share. 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 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.
Out-of-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharing
requirement to pay for a portion of drugs received is also referred to as the member’s “out-ofpocket” cost requirement.

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[Insert PACE plan definition only if there is a PACE plan in your state: PACE plan – A PACE
(Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term
care (LTC) services for frail people to help people stay independent and living in their
community (instead of moving to a nursing home) as long as possible, while getting the highquality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid
benefits through the plan. [National or multi-state plans when there is variability in the
availability of PACE insert: PACE is not available in all states. If you would like to know if
PACE is available in your state, please contact Member Services (phone numbers are printed on
the back cover of this booklet).]
Part C – see “Medicare Advantage (MA) Plan.”
Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we
will refer to the prescription drug benefit program as Part D.)
Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D
drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were
specifically excluded by Congress from being covered as Part D drugs.
[Include this definition only if Part D plan has pharmacies that offer preferred cost-sharing in
addition to those offering standard cost-sharing
Preferred cost-sharing – Preferred cost-sharing means lower cost-sharing for certain covered
Part D drugs at certain network pharmacies.]
Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
Prior Authorization – Approval in advance to get certain drugs that may or may not be on our
formulary. [Plans may delete applicable sentences if it does not require prior authorization for
any drugs.] Some drugs are covered only if your doctor or other network provider gets “prior
authorization” from us. Covered drugs that need prior authorization are marked in the formulary.
Quality Improvement Organization (QIO) – A group of practicing doctors and other health
care experts paid by the Federal government to check and improve the care given to Medicare
patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.
Quantity Limits – A management tool that is designed to limit the use of selected drugs for
quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per
prescription or for a defined period of time.
Service Area – A geographic area where a prescription drug plan accepts members if it limits
membership based on where people live. The plan may disenroll you if you permanently move
out of the plan’s service area.

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Special Enrollment Period – A set time when members can change their health or drugs plans
or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment
Period include: if you move outside the service area, if you are getting “Extra Help” with your
prescription drug costs, if you move into a nursing home, or if we violate our contract with you.
[Include this definition only if Part D plan has pharmacies that offer preferred cost-sharing in
addition to those offering standard cost-sharing
Standard Cost-sharing– Standard cost-sharing is cost-sharing other than preferred cost-sharing
offered at a network pharmacy.]
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 Social Security 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.

[This is the back cover for the EOC. Plans may add a logo and/or photographs, as long as these
elements do not make it difficult for members to find and read the plan contact information.]
[Insert 2015 plan name] Member Services
Method

Member Services – Contact Information

CALL

TTY

FAX

[Optional: insert fax number]

WRITE

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

WEBSITE

[Insert URL]

[Insert state-specific SHIP name] [If the SHIP’s name does not include the name
of the state, add: ([insert state name] SHIP)]
[Insert state-specific SHIP name] is a state program that gets money from the Federal
government to give free local health insurance counseling to people with Medicare.
[Plans with multi-state EOCs revise heading and sentence above to use “State Health Insurance
Assistance Program,” omit table, and reference exhibit or EOC section with SHIP information.]

Method

Contact Information

CALL

[Insert phone number(s)]

TTY

WRITE

[Insert address]

WEBSITE

[Insert URL]

File Type	application/pdf
File Title	2015 Medicare Prescription Drug Plan (PDP) Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Templates
Subject	Proposed revisions for 2015 Medicare Prescription Drug Plan (PDP) Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
Author	Centers for Medicare & Medicaid Services
File Modified	2014-01-23
File Created	2014-01-23