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_PPO_MAPD_ISNP_CSNP_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⚠️ Notice: This form may be outdated.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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[MA-PD PPO (and ISNPs and CSNPs) templates]
[2015 ANOC template]

[Insert 2015 plan name] ([insert plan type]) offered by [insert
MAO 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 MAO 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. Do the changes
affect the services you use? 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] and
[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.
 Check to see if your doctors and other providers will be in our network next year.
Are your doctors in our network? What about the hospitals or other providers you use?
Look in Section [insert section number] for information about our Provider Directory.
 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*

2014 (this year)

2015 (next year)

[Insert 2014 premium
amount]

[Insert 2015 premium
amount]

[Insert 2014 deductible
amount]

[Insert 2015 deductible
amount]

Maximum out-of-pocket amounts
This is the most you will pay
out-of-pocket for your covered
Part A and Part B services.
(See Section [edit section number
as needed] 2.2 for details.)

From in-network
providers: [Insert 2014 innetwork MOOP amount]

From in-network providers:
[Insert 2015 in-network
MOOP amount]

From in-network and
out-of-network providers
combined: [Insert 2014
combined MOOP amount]

From in-network and
out-of-network providers
combined: [Insert 2015
combined MOOP amount]

Doctor office visits

Primary care visits: [insert
2014 cost-sharing for
PCPs] per visit

Primary care visits: [insert
2015 cost-sharing for
PCPs] per visit

Specialist visits: [insert
2014 cost-sharing for
specialists] per visit

Specialist visits: [insert
2015 cost-sharing for
specialists] per visit

* Your premium may be higher or
lower than this amount. See Section
[edit section number as needed] 2.1
for details.
[Plans with no deductible may delete
this row.]
Yearly deductible

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

Cost

2014 (this year)

2015 (next year)

In-patient hospital stays
Includes inpatient acute, inpatient
rehabilitation, and other types of
inpatient hospital services. Inpatient
hospital care starts the day you are
formally admitted to the hospital with
a doctor’s order. The day before you
are discharged is your last inpatient
day.

[Insert 2014 cost-sharing]

[Insert 2015 cost-sharing]

Part D prescription drug coverage

Deductible: [Insert 2014
deductible amount]

Deductible: [Insert 2015
deductible amount]

Copays during the Initial
Coverage Stage:

•

(See Section [edit section number
as needed] 2.6 for details.)

•

Drug Tier 1: [Insert
2014 cost-sharing]
[Repeat for all drug
tiers.]

•

Drug Tier 1: [Insert
2015 cost-sharing]
[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 ................................................... 5

SECTION 1

Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2015 plan name] in 2015............. 5

SECTION 2
Changes to Benefits and Costs for Next Year ................................. 6
Section 2.1 – Changes to the Monthly Premium ...................................................................... 6
Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts ........................................ 6
Section 2.3 – Changes to the Provider Network ....................................................................... 7
Section 2.4 – Changes to the Pharmacy Network ..................................................................... 8
Section 2.5 – Changes to Benefits and Costs for Medical Services ......................................... 9
Section 2.6 – Changes to Part D Prescription Drug Coverage ............................................... 10
SECTION 3

Other Changes .................................................................................. 14

SECTION 4
Deciding Which Plan to Choose...................................................... 14
Section 4.1 – If you want to stay in [insert 2015 plan name] ................................................ 14
Section 4.2 – If you want to change plans .............................................................................. 14
SECTION 5

Deadline for Changing Plans ........................................................... 15

SECTION 6

Programs That Offer Free Counseling about Medicare ................ 16

SECTION 7

Programs That Help Pay for Prescription Drugs ........................... 16

SECTION 8
Questions?........................................................................................ 17
Section 8.1 – Getting Help from [insert 2015 plan name] ..................................................... 17
Section 8.2 – Getting Help from Medicare ............................................................................. 18

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

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

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 cross walks 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 MAO 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 medical and 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 health plan. You can also switch to Original Medicare.
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 MAO 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.]
[Plans that include a Part B premium reduction benefit may insert a row to describe the change
in the benefit.]
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 Your Maximum Out-of-Pocket Amounts
[Plans that include the costs of supplemental benefits in the MOOP limit may revise this
information as needed.]
To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket”
during the year. These limits are called the “maximum out-of-pocket amounts.” Once you reach
the maximum out-of-pocket amounts, you generally pay nothing for covered [insert if
applicable: Part A and Part B] services for the rest of the year.

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

Cost
In-network maximum out-of-pocket
amount

2014 (this year)

2015 (next year)

[insert 2014 in-network
MOOP amount]

[insert 2015 in-network
MOOP amount]

Your costs for covered medical services
(such as copays [insert if plan has a
deductible: and deductibles]) from innetwork providers count toward your innetwork maximum out-of-pocket
amount. [Plans with no premium may
modify the following sentence as
needed] Your plan premium and your
costs for prescription drugs do not count
toward your maximum out-of-pocket
amount.

Combined maximum out-of-pocket
amount

Once you have paid
[insert 2015 in-network
MOOP amount] out-ofpocket for covered
[insert if applicable: Part
A and Part B] services,
you will pay nothing for
your covered [insert if
applicable: Part A and
Part B] services from innetwork providers for the
rest of the calendar year.
[insert 2014 combined
MOOP amount]

Your costs for covered medical services
(such as copays [insert if plan has a
deductible: and deductibles]) from innetwork and out-of-network providers
count toward your combined maximum
out-of-pocket amount. [Plans with no
premium delete the following sentence]
Your plan premium does not count
toward your maximum out-of-pocket
amount.

[insert 2015 combined
MOOP amount]
Once you have paid
[insert 2015 combined
MOOP amount] out-ofpocket for covered
[insert if applicable: Part
A and Part B] services
from in-network
providers, you will pay
nothing for your covered
[insert if applicable: Part
A and Part B] services
from in-network or outof-network providers for
the rest of the calendar
year.

Section 2.3 – Changes to the Provider Network
[Plans with no changes to their provider network delete this section.]
[Insert as applicable: We included a copy of our Provider Directory in the envelope with this
booklet. OR An updated Provider 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 Provider

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

Directory. Please review the 2015 Provider Directory to see if your providers are in our
network.
It is important that you know that we may make changes to the hospitals, doctors and specialist
(providers) that are part of your plan during the year. There are a number of reasons why your
provider might leave your plan but if your doctor or specialist does leave your plan you have
certain rights and protections summarized below:
•

Even though our network of providers may change during the year, Medicare requires
that we furnish you with uninterrupted access to qualified doctors and specialists.

•

When possible we will provide you with at least 30 days’ notice that your provider is
leaving our plan so that you have time to select a new provider.

•

We will assist you in selecting a new qualified provider to continue managing your health
care needs.

•

If you are undergoing medical treatment you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted.

•

If you believe we have not furnished you with a qualified provider to replace your
previous provider or that your care is not being appropriately managed you have the right
to file an appeal of our decision.

•

If you find out your doctor or specialist is leaving your plan please contact us so we can
assist you in finding a new provider and managing your care.

Section 2.4 – 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 cost- sharing 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 2.5 – Changes to Benefits and Costs for Medical Services
[If there are no changes in benefits or in cost-sharing, revise heading to “There are no changes to
your benefits or amounts you pay for medical services” and replace the rest of this section with:
Our benefits and what you pay for these covered medical services will be exactly the same in
2015 as they are in 2014.]
We are changing our coverage for certain medical services next year. The information below
describes these changes. For details about the coverage and costs for these services, see Chapter 4,
Medical Benefits Chart (what is covered and what you pay), in your 2015 Evidence of Coverage.
[The table must include: (1) all new benefits that will be added or 2014 benefits that will end for
2015, including any new optional supplemental benefits (plans must indicate these optional
supplemental benefits are available for an extra premium); (2) new limitations or restrictions on
Part C benefits for CY 2015; and (3) all changes in cost-sharing for 2015 for covered medical
services, including any changes to service category out-of-pocket maximums and cost-sharing
for optional supplemental benefits (plans must indicate these optional supplemental benefits are
available for an extra premium).]
Cost
[Insert benefit name]

2014 (this year)
[For benefits that were not
covered in 2014 insert:
[insert benefit name] is not
covered.]
[For benefits with a copayment
insert:
You pay a $[insert 2014
copayment amount] copay
[insert language as needed to
accurately describe the benefit,
e.g., “per office visit”].]
[For benefits with a
coinsurance insert:
You pay [insert 2014
coinsurance percentage]% of
the total cost
[insert language as needed to
accurately describe the benefit,
e.g., “for up to one visit per
year”].]

[Insert benefit name]

[Insert 2014 cost/coverage,
using format described above.]

2015 (next year)
[For benefits that are not
covered in 2015 insert: [insert
benefit name] is not covered.]
[For benefits with a copayment
insert:
You pay a $[insert 2015
copayment amount] copay
[insert language as needed to
accurately describe the benefit,
e.g., “per office visit”].]
[For benefits with a
coinsurance insert:
You pay [insert 2015
coinsurance percentage]% of
the total cost
[insert language as needed to
accurately describe the benefit,
e.g., “for up to one visit per
year”].]

[Insert 2015 cost/coverage,
using format described above.]

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

Section 2.6 – 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 9 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 5, 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.

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

[Plans may include additional information about processes for transitioning current enrollees to
formulary drugs when your formulary changes relative to the previous plan year.]
[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 received 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 6, 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 6, Sections 6 and 7, in the [insert as applicable:
attached OR enclosed] Evidence of Coverage.)
Changes to the Deductible Stage
Cost
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.]
Cost
Stage 2: Initial Coverage Stage
[Plans with no deductible delete the first
sentence] Once you pay the yearly
deductible, you move to the Initial
Coverage Stage. During this stage, the
plan pays its share of the cost of your
drugs and you pay your share of the
cost.
The costs in this row are for a onemonth ([insert number of days in a onemonth supply]-day) supply when you fill
your prescription at a network pharmacy
that provides standard cost-sharing. For
information about the costs [insert as
applicable: for a long-term supply; at a
network pharmacy that offers preferred
cost-sharing; or for mail-order
prescriptions], look in Chapter 6, 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.]

2014 (this year)

2015 (next year)

Your cost for a onemonth 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 $2,850, you will
move to the next stage
(the Coverage Gap
Stage). OR you have
paid $4,550 out-of-pocket
for Part D drugs, you will
move to the next stage
(the Catastrophic
Coverage Stage).]

______________
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
Stage 2: Initial Coverage Stage
[Plans with no deductible delete the
first sentence] Once you pay the
yearly deductible, you move to the
Initial Coverage Stage. During this
stage, the plan pays its share of the
cost of your drugs and you pay
your share of the cost.
The costs in this row are for a onemonth ([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 mailorder prescriptions], look in Chapter
6, 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.]

2014 (this year)

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 $2,850, you will
move to the next stage (the
Coverage Gap Stage). OR
you have paid $4,550 outof-pocket for Part D drugs,
you will move to the next
stage (the Catastrophic
Coverage Stage).]

______________
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 6, 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 or
change to Original Medicare 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:
Step 1: Learn about and compare your choices
•

You can join a different Medicare health plan,

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

•

--OR-- You can change to Original Medicare. If you change to Original Medicare, you
will need to decide whether to join a Medicare drug plan and whether to buy a Medicare
supplement (Medigap) policy.

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 MAO 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 health plan, enroll in the new plan. You will
automatically be disenrolled from [insert 2015 plan name].

•

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

•

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).
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 plan or to Original Medicare 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 10, Section 2.3 of the Evidence of Coverage.

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

If you enrolled in a Medicare Advantage plan for January 1, 2015, and don’t like your plan
choice, you can switch to Original Medicare between January 1 and February 14, 2015. For more
information, see Chapter 10, Section 2.2 of the Evidence of Coverage.
[I-SNPs: replace text above with the following:
You can change your Medicare coverage at any time. You can change to any other Medicare
health plan (either with or without Medicare prescription drug coverage) or switch to Original
Medicare (either with or without a separate Medicare prescription drug plan) at any time.]

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
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;

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

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);
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 no Part D drug cost-sharing should delete this section] [Plans with an ADAP
in their state(s) that do NOT provide Insurance Assistance should delete this bullet.]
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.]
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.

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

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 provider network (Provider 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 health 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 “Find health & drug plans.”)
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 Health Benefits and Services and 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 health care and prescription drug
coverage from January 1 – December 31, 2015. It explains how to get coverage for the health
care services and 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 MAO name]. (When this Evidence of
Coverage says “we,” “us,” or “our,” it means [insert MAO 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 health plan and how to use this
booklet. Tells about materials we will send you, your plan premium, your
plan membership card, and keeping your membership record up to date.

Chapter 2.

Important phone numbers and resources ........................................... 20
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 medical services ........................ 40
Explains important things you need to know about getting your medical care
as a member of our plan. Topics include using the providers in the plan’s
network and how to get care when you have an emergency.

Chapter 4.

Medical Benefits Chart (what is covered and what you pay) ............. 54
Gives the details about which types of medical care are covered and not
covered for you as a member of our plan. Explains how much you will pay
as your share of the cost for your covered medical care.

Chapter 5.

Using the plan’s coverage for your Part D prescription drugs .......... 91
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.

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

Chapter 6.

What you pay for your Part D prescription drugs ............................. 115
Tells about the [insert number of stages] stages of drug coverage ([delete
any stages that are not applicable] Deductible Stage, Initial Coverage
Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these
stages affect what you pay for your drugs. [Plans without drug 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 7.

Asking us to pay our share of a bill you have received for
covered medical services or drugs .................................................... 143
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 services or drugs.

Chapter 8.

Your rights and responsibilities ......................................................... 150
Explains the rights and responsibilities you have as a member of our plan.
Tells what you can do if you think your rights are not being respected.

Chapter 9.

What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) ....................................... 161
Tells you step-by-step what to do if you are having problems or concerns as a
member of our plan.
•

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

•

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

Chapter 10. Ending your membership in the plan .................................................. 217
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 11. Legal notices ......................................................................................... 227
Includes notices about governing law and about nondiscrimination.
Chapter 12. Definitions of important words ............................................................ 229
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 1.1
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 PPO ....... 4
You are currently enrolled in [insert 2015 plan name], which is a
specialized Medicare Advantage Plan (“Special Needs Plan”)....................... 4
What is the Evidence of Coverage booklet about? .......................................... 5
What does this Chapter tell you? ..................................................................... 5
What if you are new to [insert 2015 plan name]? ........................................... 5
Legal information about the Evidence of Coverage ........................................ 6

SECTION 2
Section 2.1
Section 2.2
Section 2.3

What makes you eligible to be a plan member? .............................. 6
Your eligibility requirements .......................................................................... 6
What are Medicare Part A and Medicare Part B? ........................................... 7
Here is the plan service area for [insert 2015 plan name] .............................. 8

SECTION 3
Section 3.1

What other materials will you get from us? ..................................... 8
Your plan membership card – Use it to get all covered care and
prescription drugs ............................................................................................ 8
The Provider Directory: Your guide to all providers in the plan’s network ... 9
The Pharmacy Directory: Your guide to pharmacies in our network ........... 10
The plan’s List of Covered Drugs (Formulary) ............................................ 11
The Part D Explanation of Benefits (the “Part D EOB”): Reports with a
summary of payments made for your Part D prescription drugs .................. 11

Section 3.2
Section 3.3
Section 3.4
Section 3.5

SECTION 4
Section 4.1
Section 4.2
Section 4.3

Your monthly premium for [insert 2015 plan name] ...................... 11
How much is your plan premium? ................................................................ 11
There are several ways you can pay your plan premium .............................. 14
Can we change your monthly plan premium during the year?...................... 16

SECTION 5
Section 5.1

Please keep your plan membership record up to date ................. 17
How to help make sure that we have accurate information about you .......... 17

SECTION 6
Section 6.1

We protect the privacy of your personal health information ........ 18
We make sure that your health information is protected ............................... 18

SECTION 7
Section 7.1

How other insurance works with our plan ..................................... 18
Which plan pays first when you have other insurance? ................................ 18

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 PPO

You are covered by Medicare, and you have chosen to get your Medicare health care and your
prescription drug coverage through our plan, [insert 2015 plan name].
There are different types of Medicare health plans. [Insert 2015 plan name] is a Medicare
Advantage PPO Plan (PPO stands for Preferred Provider Organization). Like all Medicare
health plans, this Medicare PPO is approved by Medicare and run by a private company.
[I-SNPs and C-SNPs use the following language for Section 1.1 in place of the language
above:
Section 1.1

You are currently enrolled in [insert 2015 plan name], which is
a specialized Medicare Advantage Plan (“Special Needs Plan”)

You are covered by Medicare, and you have chosen to get your Medicare health care and
prescription drug coverage through our plan, [insert 2015 plan name].
[I-SNPs: insert the following three paragraphs:
There are different types of Medicare health plans. [Insert 2015 plan name] is a specialized
Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means its benefits are
designed for people with special health care needs. [Insert 2015 plan name] is designed
specifically for people who live in an institution (like a nursing home) or who need a level of
care that is usually provided in a nursing home.
Our plan includes access to a network of providers who specialize in treating patients who need
this level of nursing care. As a member of the plan, you get specially tailored benefits and have
all your care coordinated through our plan.
Like all Medicare health plans, this Medicare Special Needs Plan is approved by Medicare and
run by a private company.]
[C-SNPs: insert the following three paragraphs:
There are different types of Medicare health plans. [Insert 2015 plan name] is a specialized
Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means its benefits are
designed for people with special health care needs. [Insert 2015 plan name] is designed to
provide additional health benefits that specifically help people who have [insert condition(s)].

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

Our plan provides access to a network of providers who specialize in treating [insert
condition(s)]. It also includes health programs designed to serve the specialized needs of people
with [insert as applicable: this condition OR these conditions].] In addition, our plan covers
prescription drugs to treat most medical conditions, including the drugs that are usually used to
treat [insert condition(s)]. As a member of the plan, you get benefits specially tailored to your
condition and have all your care coordinated through our plan.
Like all Medicare health plans, this Medicare Special Needs 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 medical care and
prescription drugs covered 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 MAO name]. (When this Evidence of
Coverage says “we,” “us,” or “our,” it means [insert MAO name]. When it says “plan” or “our
plan,” it means [insert 2015 plan name].)
The word “coverage” and “covered services” refers to the medical care and services and the
prescription drugs 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
services are available to you. We encourage you to set aside some time to look through this
Evidence of Coverage booklet.
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).

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

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 both Medicare Part A and Medicare Part B

•

[C-SNPs: delete if not applicable] -- and -- you do not have End-Stage Renal Disease
(ESRD), with limited exceptions, such as if you develop ESRD when you are already a
member of a plan that we offer, or you were a member of a different plan that was
terminated.

•

[I-SNPs and C-SNPs insert: -- and -- you meet the special eligibility requirements
described below.]

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

[I-SNPs and C-SNPs insert this section as applicable to your plan type:
Special eligibility requirements for our plan
[Chronic/disabling condition SNPs, insert: Our plan is designed to meet the specialized needs of
people who have certain medical conditions. To be eligible for our plan, you must have [insert
condition(s)].]
[Institutional SNPs, insert: Our plan is designed to meet the specialized needs of people who
need a level of care that is usually provided in a nursing home.]
[Plans that limited enrollment to those residing in an institution insert: To be eligible for our
plan, you must live in one of our network nursing homes. [Insert as appropriate: Please see the
plan’s Provider Directory for a list of our network nursing home. Or call Member Services
(phone numbers are printed on the back cover of this booklet) and ask us to send you a list. OR
Here is a list of our network nursing homes:
•

[Insert list of contracted facilities]]

[Plans that also enroll those who are NFLOC certified insert: To be eligible for our plan, you
must meet one of the two requirements listed below.
•

You live in one of our network nursing homes. [Insert as appropriate: Please see the
plan’s Provider Directory for a list of our network nursing home. Or call Member
Services (phone numbers are printed on the back cover of this booklet) and ask us to send
you a list. OR Here is a list of our network nursing homes:
o [Insert list of contracted facilities]

•

-or – you live at home and [insert state] has certified that you need the type of care that is
usually provided in a nursing home.]]

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:
•

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).

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

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 [if a
“continuation area” is offered under 42 CFR 422.54, insert “generally” here, and add a
sentence describing the continuation area] 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. Use county name only if approved for entire county. For partially approved
counties, use county name plus zip code. Examples of the format for describing the service area
are provided below. If needed, plans may insert more than one row to describe their services
area:
Our service area includes all 50 states
Our service area includes these states: [insert states]
Our service area includes these counties in [insert state]: [insert counties]
Our service area includes these parts of counties in [insert state]: [insert county], the following
zip codes only [insert zip codes]]
[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 switch to Original Medicare or 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 care and
prescription drugs

[Plans that use separate membership cards for health and drug coverage should edit the
following section to reflect the use of multiple cards.]

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

While you are a member of our plan, you must use your membership card for our plan whenever
you get any services covered by this plan and for prescription drugs you get at network
pharmacies. Here’s a sample membership card to show you what yours will look like:
[Insert picture of front and back of member ID card. Mark it as a sample card (for example, by
superimposing the word “sample” on the image of the card.]
As long as you are a member of our plan you must not use your red, white, and blue
Medicare card to get covered medical services (with the exception of routine clinical research
studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in
case you need it later.
Here’s why this is so important: If you get covered services using your red, white, and blue
Medicare card instead of using your [insert 2015 plan name] membership card while you are a
plan member, you may have to pay the full cost yourself.
If your plan membership card is damaged, lost, or stolen, call Member Services right away and
we will send you a new card. (Phone numbers for Member Services are printed on the back cover
of this booklet.)
Section 3.2

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

[Plans with combined provider and pharmacy directories may combine and edit the provider
and pharmacy directory sections (including section titles) to describe the combined document.
Plans should renumber sections as needed and revise references to “Provider Directory” to use
the actual name of the document throughout the template.]
The Provider Directory lists our network providers.
What are “network providers”?
Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that have an agreement with us to accept our payment
and any plan cost-sharing as payment in full. We have arranged for these providers to deliver
covered services to members in our plan.
Why do you need to know which providers are part of our network?
As a member of our plan, you can choose to receive care from out-of-network providers. Our
plan will cover services from either in-network or out-of-network providers, as long as the
services are covered benefits and medically necessary. However, if you use an out-of-network
provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using
the plan’s coverage for your medical services) for more specific information.

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

[Regional PPOs that CMS has granted permission to use the exception in § 422.112(a) (1) (ii) to
meet access requirements should insert: Because our Plan is a Regional Preferred Provider
Organization, if no contracted network provider is readily available you can access care at innetwork cost-sharing from an out-of-network provider. Call Member Services to let us know you
need to see an out-of-network provider or to get help finding an out-of-network provider.]
If you don’t have your copy of the Provider Directory, you can request a copy from Member
Services (phone numbers are printed on the back cover of this booklet). You may ask Member
Services for more information about our network providers, including their qualifications. [Plans
may add additional information describing the information available in the provider directory,
on the plan’s website, or from Member Services. For example: You can also see the Provider
Directory at [insert URL], or download it from this website. Both Member Services and the
website can give you the most up-to-date information about changes in our network providers.]
Section 3.3

The Pharmacy Directory: Your guide to pharmacies in our
network

[Plans with combined provider and pharmacy directories may combine and edit the provider
and pharmacy directory sections (including section titles) to describe the combined document.
Plans should renumber sections as needed and revise references to the “Pharmacy Directory” to
use the actual name of the document throughout the template.]
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.]

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

Section 3.4

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.
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 3.5

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, or others on your behalf,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 6 (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].

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

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.]
[Plans with no premium should replace the preceding paragraph with: You do not pay a
separate monthly plan premium for [insert 2015 plan name]. 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).]
[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
[Plans with no monthly premium: Omit this subsection.]
[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. [Insert as applicable: This situation is OR These situations are] described below.
•

[Insert if applicable: If you signed up for extra benefits, also called “optional
supplemental benefits”, then you pay an additional premium each month for these extra
benefits. If you have any questions about your plan premiums, please call Member
Services (phone numbers are printed on the back cover of this booklet). [If the plan

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

describes optional supplemental benefits within Chapter 4, then the plan must include the
premium amounts for those benefits in this section.]]
•

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 at least as good as Medicare’s standard 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.
o If you are required to pay the late enrollment penalty, the amount of your penalty
depends on how long you waited before you enrolled in drug coverage or how
many months you were without drug coverage after you became eligible. Chapter
6, Section 10 explains the late enrollment penalty.
o 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
[Plans that include a Part B premium reduction benefit may describe the benefit within this
section.]
[Plans with no monthly premium, omit: In addition to paying the monthly plan premium,] many
members are required to pay other Medicare premiums. As explained in Section 2 above, in
order to be eligible for our plan, you must be entitled to Medicare Part A and enrolled in
Medicare Part B. For that reason, some plan members (those who aren’t eligible for premiumfree Part A) pay a premium for Medicare Part A. And most plan members pay a premium for
Medicare Part B. You must continue paying your Medicare premiums to remain a member
of the plan.
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 6,
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

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

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

[Plans indicating in Section 4.1 that there is no monthly premium: Rename this section, “If you
pay a Part D late enrollment penalty, there are several ways you can pay your penalty,” and use
the alternative text as instructed below.]
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.
[Plans without a monthly premium: Replace the preceding two paragraphs with the following: If
you pay a Part D late enrollment penalty, there are [insert number of payment options] ways you
can pay the penalty. [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 late enrollment penalty, 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 late enrollment penalty 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
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.]

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

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 [plans with a premium insert: plan
premium] [plans without a premium insert: late enrollment penalty] taken out of
your monthly Social Security check
You can have the [plans with a premium insert: plan premium] [plans without a premium insert:
late enrollment penalty] taken out of your monthly Social Security check. Contact Member
Services for more information on how to pay your [plans with a premium insert: plan premium]
[plans without a premium insert: penalty] 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 [plans with a premium insert:
plan premium] [plans without a premium insert: late enrollment penalty]
[Plans that do not disenroll members for non-payment may modify this section as needed.]
Your [plans with a premium insert: plan premium] [plans without a premium insert: late
enrollment penalty] is due in our office by the [insert day of the month]. If we have not received
your [plans with a premium insert: premium] [plans without a premium insert: penalty] payment
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 [plans with a premium insert: plan premium] [plans without a
premium insert: late enrollment penalty payment] within [insert length of plan grace period]. If
you are required to pay a late enrollment penalty, you must pay the penalty to keep your
prescription drug coverage.
If you are having trouble paying your [plans with a premium insert: premium] [plans without a
premium insert: late enrollment penalty] on time, please contact Member Services to see if we
can direct you to programs that will help with your [plans with a premium insert: plan premium]
[plans without a premium insert: penalty]. (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 [plans with a premium
insert: premium] [plans without a premium insert: late enrollment penalty], 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

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

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 [plans with a premium insert:
premium] [plans without a premium insert: late enrollment penalty], you will have health
coverage under Original Medicare.
[Insert if applicable: At the time we end your membership, you may still owe us for [plans with
a premium insert: premiums] [plans without a premium insert: the penalty] you have not paid.
[Insert one or both statements as applicable for the plan: We have the right to pursue collection
of [plans with a premium insert: the premiums] [plans without a premium insert: the penalty
amount] 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 9, Section 10 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. [Plans with no premium replace next sentence with the following: We are not allowed to
begin charging a monthly plan premium during the year.] 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.
[Plans with no premium replace the previous paragraph with the following: However, in some
cases, you may need to start paying or may be able to stop paying a late enrollment penalty. (The
late enrollment penalty may apply if you had a continuous period of 63 days or more when you
didn’t have “creditable” prescription drug coverage.) This could happen if you become eligible

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

for the “Extra Help” program or if you lose your eligibility for the “Extra Help” program during
the year:
•

If you currently pay the late enrollment penalty and become eligible for “Extra Help”
during the year, you would be able to stop paying your penalty.

•

If the “Extra Help” program is currently paying your late enrollment penalty and you lose
your eligibility during the year, you would need to start paying your penalty.

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 [insert as appropriate: including your
Primary Care Provider/Medical Group/IPA].
The doctors, hospitals, pharmacists, and other providers in the plan’s network need to have
correct information about you. These network providers use your membership record to
know what services and 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.
Let us know about these changes:
•

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

•

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

•

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

•

If you have been admitted to a nursing home.

•

If you receive care in an out-of-area or out-of-network hospital or emergency room.

•

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

•

If you are participating in a clinical research study.

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.]

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

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.]
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That’s because we must coordinate any other coverage you
have with your benefits under our plan. (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 8, Section 1.4 of this booklet.

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.

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

•

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
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) ........................ 21

SECTION 2

Medicare (how to get help and information directly from the
Federal Medicare program) ................................................................ 28

SECTION 3

State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare) ............ 30

SECTION 4

Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare) ....................... 31

SECTION 5

Social Security .................................................................................. 32

SECTION 6

Medicaid (a joint Federal and state program that helps with
medical costs for some people with limited income and
resources) .......................................................................................... 33

SECTION 7

Information about programs to help people pay for their
prescription drugs ............................................................................ 34

SECTION 8

How to contact the Railroad Retirement Board ............................. 38

SECTION 9

Do you have “group insurance” or other health insurance
from an employer? ........................................................................... 39

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 C and Part D issues indicated
below, you may combine the appropriate sections and revise the section titles and paragraphs as
needed.]

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
medical care
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your medical services. For more information on asking for coverage decisions
about your medical care, see Chapter 9 (What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)).
You may call us if you have questions about our coverage decision process.
Method

Coverage Decisions for Medical Care – 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 a different TTY number for
accepting expedited organization determinations, also include that
number here.]

FAX

[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited organization determinations, also include that
number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited organization determinations, also include that address here.]

WEBSITE

[Optional: 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 medical care
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 medical care, see Chapter 9 (What to do if
you have a problem or complaint (coverage decisions, appeals, complaints)).
Method

Appeals for Medical Care – Contact Information

CALL

TTY

FAX

[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited appeals, also include that number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited appeals, also include that address here.]

WEBSITE

[Optional: 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 medical care
You can make a complaint about us or one of our network providers, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If you have a problem 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
medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions,
appeals, complaints)).
Method

Complaints about Medical Care – Contact Information

CALL

TTY

FAX

[Optional: insert fax number] [Note: If you have a different fax number
for accepting expedited grievances, also include that number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited grievances, also include that address 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

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 9 (What to do if you have a problem
or complaint (coverage decisions, appeals, complaints)).
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 9
(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]

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

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

your Part D prescription drugs, see Chapter 9 (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.

Where to send a request asking us to pay for our share of the cost for medical
care or a drug you have received
For more information on situations in which you may need to ask us for reimbursement or to
pay a bill you have received from a provider, see Chapter 7 (Asking us to pay our share of a
bill you have received for covered medical services or 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 9 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.
[Plans with different addresses and/or numbers for Part C and Part D claims may modify the
table below or add a second table as needed.]

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

Method

Payment Request – 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]

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 Advantage organizations
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.

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

Method

Medicare – Contact Information

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.
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.)

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

SECTION 3

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

[Organizations offering plans in multiple states: Revise 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 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]

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

SECTION 4

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

[Organizations offering plans in multiple states: Revise 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.
You should contact [insert state-specific QIO name] in any of these situations:
•

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

•

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

•

You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.

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]

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

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

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.
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 to 7:00 pm, Monday through Friday.

WEBSITE

http://www.ssa.gov

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

SECTION 6

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

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

•

Qualified Individual (QI): Helps pay Part B premiums.

•

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.]

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

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

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, yearly
deductible, and prescription copayments. This “Extra Help” also counts toward your out-ofpocket costs.
People with limited income and resources may qualify for “Extra Help.” Some people
automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people
who automatically qualify for “Extra Help.”
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;

•

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

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

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 US 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 6, 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.
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 6, 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 (Part D 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.

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

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
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 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.

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

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
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].

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

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
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

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

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 medical services

Chapter 3. Using the plan’s coverage for your medical services
SECTION 1
Section 1.1
Section 1.2
SECTION 2
Section 2.1
Section 2.2
Section 2.3
Section 2.4
Section 2.5
SECTION 3
Section 3.1
Section 3.2
SECTION 4
Section 4.1
Section 4.2
SECTION 5
Section 5.1
Section 5.2
SECTION 6
Section 6.1
Section 6.2

SECTION 7
Section 7.1

Things to know about getting your medical care covered as
a member of our plan ....................................................................... 41
What are “network providers” and “covered services”? ............................... 41
Basic rules for getting your medical care covered by the plan ..................... 41
Using network and out-of-network providers to get your
medical care ...................................................................................... 42
You [insert as applicable: may OR must] choose a Primary Care
Provider (PCP) to provide and oversee your medical care ........................... 42
What kinds of medical care can you get without getting approval in
advance from your PCP? ............................................................................... 43
How to get care from specialists and other network providers ..................... 43
How to get care from out-of-network providers ........................................... 44
How to get care if you live in a non-network area ........................................ 45
How to get covered services when you have an emergency
or urgent need for care .................................................................... 46
Getting care if you have a medical emergency ............................................. 46
Getting care when you have an urgent need for care .................................... 47
What if you are billed directly for the full cost of your
covered services? ............................................................................ 48
You can ask us to pay our share of the cost of covered services .................. 48
If services are not covered by our plan, you must pay the full cost .............. 48
How are your medical services covered when you are in a
“clinical research study”? ............................................................... 48
What is a “clinical research study”? .............................................................. 48
When you participate in a clinical research study, who pays for what? ....... 49
Rules for getting care covered in a “religious non-medical
health care institution” .................................................................... 51
What is a religious non-medical health care institution? .............................. 51
What care from a religious non-medical health care institution is covered
by our plan? ................................................................................................... 51
Rules for ownership of durable medical equipment ..................... 52
Will you own the durable medical equipment after making a certain
number of payments under our plan? ............................................................ 52

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 1

Things to know about getting your medical care
covered as a member of our plan

This chapter explains what you need to know about using the plan to get your medical care
coverage. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, and other medical care that are covered by the plan.
For the details on what medical care is covered by our plan and how much you pay when you
get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what
is covered and what you pay).
Section 1.1

What are “network providers” and “covered services”?

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

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

•

“Network providers” are the doctors and other health care professionals, medical
groups, hospitals, and other health care facilities that have an agreement with us to accept
our payment and your cost-sharing amount as payment in full. We have arranged for
these providers to deliver covered services to members in our plan. [Plans may delete the
next sentence if it is not applicable] The providers in our network generally bill us
directly for care they give you. When you see a network provider, you usually pay only
your share of the cost for their services.

•

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

Section 1.2

Basic rules for getting your medical care covered by the plan

As a Medicare health plan, [insert 2015 plan name] must cover all services covered by Original
Medicare and must follow Original Medicare’s coverage rules.
[Insert 2015 plan name] will generally cover your medical care as long as:
•

The care you receive is included in the plan’s Medical Benefits Chart (this chart is in
Chapter 4 of this booklet).

•

The care you receive is considered medically necessary. “Medically necessary” means
that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment
of your medical condition and meet accepted standards of medical practice.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
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•

You receive your care from a provider who is eligible to provide services under
Original Medicare. As a member of our plan, you can receive your care from either a
network provider or an out-of-network provider (for more about this, see Section 2 in this
chapter).
o The providers in our network are listed in the Provider Directory.
o If you use an out-of-network provider, your share of the costs for your covered
services may be higher.
o [RPPOs that CMS has granted permission to use the exception in § 422.112(a) (1)
(ii) to meet access requirements should insert: Because our plan is a Regional
Preferred Provider Organization, if there isn’t a network provider available for you
to see, you can go to an out-of-network provider but still pay the in-network
amounts.]
o Please note: While you can get your care from an out-of-network provider, the
provider must be eligible to participate in Medicare. Except for emergency care, we
cannot pay a provider who is not eligible to participate in Medicare. If you go to a
provider who is not eligible to participate in Medicare, you will be responsible for
the full cost of the services you receive. Check with your provider before receiving
services to confirm that they are eligible to participate in Medicare.

SECTION 2

Using network and out-of-network providers to get
your medical care

Section 2.1

You [insert as applicable: may OR must] choose a Primary
Care Provider (PCP) to provide and oversee your medical care

[Note: Insert this section only if plan uses PCPs. Plans may edit this section to refer to a
Physician of Choice (POC) instead of PCP.]
What is a “PCP” and what does the PCP do for you?
[Plans should describe the following in the context of their plans:
•
•
•
•
•

What is a PCP?
What types of providers may act as a PCP?
Explain the role of a PCP in your plan.
What is the role of the PCP in coordinating covered services?
What is the role of the PCP in making decisions about or obtaining prior authorization, if
applicable?]

How do you choose your PCP?
[Plans should describe how to choose a PCP.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

Changing your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might
leave our plan’s network of providers and you would have to find a new PCP in our plan [PPOs
with lower cost-sharing for network providers insert: or you will pay more for covered services].
[Plans should describe how to change a PCP and indicate when that change will take effect
(e.g., on the first day of the month following the date of the request, immediately upon receipt of
request, etc.).]
Section 2.2

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

[Note: Insert this section only if plans use PCPs or require referrals to network providers.]
You can get services such as those listed below without getting approval in advance from your
PCP.
•

Routine women’s health care, which includes breast exams, screening mammograms (xrays of the breast), Pap tests, and pelvic exams [insert if appropriate: as long as you get
them from a network provider].

•

Flu shots [insert if applicable: Hepatitis B vaccinations, and pneumonia vaccinations]
[insert if appropriate: as long as you get them from a network provider].

•

Emergency services from network providers or from out-of-network providers.

•

Urgently needed care from in-network providers or from out-of-network providers when
network providers are temporarily unavailable or inaccessible, e.g., when you are
temporarily outside of the plan’s service area.

•

Kidney dialysis services that you get at a Medicare-certified dialysis facility when you
are temporarily outside the plan’s service area. [Plans may insert requests here, e.g., If
possible, please let us know before you leave the service area so we can help arrange for
you to have maintenance dialysis while you are away.]

•

[Plans should add additional bullets as appropriate.]

Section 2.3

How to get care from specialists and other network providers

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

Oncologists care for patients with cancer.

•

Cardiologists care for patients with heart conditions.

•

Orthopedists care for patients with certain bone, joint, or muscle conditions.

[Plans should describe how members access specialists and other network providers, including:

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

•
•

•

What is the role (if any) of the PCP in referring members to specialists and other
providers?
Include an explanation of the process for obtaining Prior Authorization (PA), including
who makes the PA decision (e.g., the plan, PCP, another entity) and who is responsible
for obtaining the prior authorization (e.g., PCP, member). Refer members to Chapter 4,
Section 2.1 for information about which services require prior authorization.
Explain if the selection of a PCP results in being limited to specific specialists or
hospitals to which that PCP refers, i.e. sub-network, referral circles.]

What if a specialist or another network provider leaves our plan?
We may make changes to the hospitals, doctors, and specialists (providers) that are part of your
plan during the year. There are a number of reasons why your provider might leave your plan but
if your doctor or specialist does leave your plan you have certain rights and protections that are
summarized below:
•

Even though our network of providers may change during the year, Medicare requires
that we furnish you with uninterrupted access to qualified doctors and specialists.

•

When possible we will provide you with at least 30 days’ notice that your provider is
leaving our plan so that you have time to select a new provider.

•

We will assist you in selecting a new qualified provider to continue managing your health
care needs.

•

If you are undergoing medical treatment you have the right to request, and we will work
with you to ensure, that the medically necessary treatment you are receiving is not
interrupted.

•

If you find out your doctor or specialist is leaving your plan please contact us so we can
assist you in finding a new provider and managing your care.

[Plans should provide contact information for assistance.]
Section 2.4

How to get care from out-of-network providers

As a member of our plan, you can choose to receive care from out-of-network providers. Our
plan will cover services from either in-network or out-of-network providers, as long as the
services are covered benefits and are medically necessary. However, if you use an out-ofnetwork provider, your share of the costs for your covered services may be higher. Here are
other important things to know about using out-of-network providers:
•

You can get your care from an out-of-network provider, however, in most cases that
provider must be eligible to participate in Medicare. Except for emergency care, we

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

cannot pay a provider who is not eligible to participate in Medicare. If you receive care
from a provider who is not eligible to participate in Medicare, you will be responsible for
the full cost of the services you receive. Check with your provider before receiving
services to confirm that they are eligible to participate in Medicare.
•

You don’t need to get a referral or prior authorization when you get care from out-ofnetwork providers. However, before getting services from out-of-network providers you
may want to ask for a pre-visit coverage decision to confirm that the services you are
getting are covered and are medically necessary. (See Chapter 9, Section 4 for
information about asking for coverage decisions.) This is important because:
o Without a pre-visit coverage decision, if we later determine that the services are
not covered or were not medically necessary, we may deny coverage and you will
be responsible for the entire cost. If we say we will not cover your services, you
have the right to appeal our decision not to cover your care. See Chapter 9 (What
to do if you have a problem or complaint) to learn how to make an appeal.

•

[RPPOs that CMS has granted permission to use the exception in § 422.112(a) (1) (ii) to
meet access requirements should insert: Because our plan is a Regional Preferred
Provider Organization, if no contracted network provider is readily available you can
access care at in-network cost-sharing from an out-of-network provider. Call Member
Services to let us know you need to see an out-of-network provider, or to get help finding
an out-of-network provider. (Phone numbers for Member Services are printed on the
back cover of this booklet.)]

•

It is best to ask an out-of-network provider to bill the plan first. But, if you have already
paid for the covered services, we will reimburse you for our share of the cost for covered
services. Or if an out-of-network provider sends you a bill that you think we should pay,
you can send it to us for payment. See Chapter 7 (Asking us to pay our share of a bill you
have received for covered medical services or drugs) for information about what to do if
you receive a bill or if you need to ask for reimbursement.

•

If you are using an out-of-network provider for emergency care, urgently needed care, or
out-of-area dialysis, you may not have to pay a higher cost-sharing amount. See Section 3
for more information about these situations.

Section 2.5

How to get care if you live in a non-network area

[RPPOs: If there are portions of your RPPO service area where you have not met Medicare
network adequacy requirements, you must insert this section and explain to your enrollees the
process they must follow to find providers who will treat them (see 422.111(b)(3)(ii)). The
expectation is that enrollees in non-network areas will receive all necessary assistance in
obtaining access to services, which may require the RPPO to pay more than the Original
Medicare payment rate to ensure access. Enrollees in non-network areas can only be charged
the in-network (i.e., preferred) cost-sharing amount for plan-covered services.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 3

How to get covered services when you have an
emergency or urgent need for care

Section 3.1

Getting care if you have a medical emergency

What is a “medical emergency” and what should you do if you have one?
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.
If you have a medical emergency:
• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval or a
referral first from your PCP.
• [Plans add if applicable: As soon as possible, make sure that our plan has been told
about your emergency. We need to follow up on your emergency care. You or someone
else should call to tell us about your emergency care, usually within 48 hours. [Plans
must provide either the phone number and days and hours of operation or explain where
to find the number (e.g., on the back the plan membership card).]]
What is covered if you have a medical emergency?
You may get covered emergency medical care whenever you need it, anywhere in the United
States or its territories. Our plan covers ambulance services in situations where getting to the
emergency room in any other way could endanger your health. For more information, see the
Medical Benefits Chart in Chapter 4 of this booklet.
[Plans that offer a supplemental benefit covering emergencies or ambulance services outside of
the country, mention the benefit here and then refer members to Chapter 4 for more
information.]
If you have an emergency, we will talk with the doctors who are giving you emergency care
to help manage and follow up on your care. The doctors who are giving you emergency care
will decide when your condition is stable and the medical emergency is over.
[Plans may modify this paragraph as needed to address the post-stabilization care for your
plan.] After the emergency is over you are entitled to follow-up care to be sure your condition
continues to be stable. Your follow-up care will be covered by our plan. If you get your
follow-up care from out-of-network providers, you will pay the higher out-of-network costsharing.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

What if it wasn’t a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long
as you reasonably thought your health was in serious danger, we will cover your care.
However, after the doctor has said that it was not an emergency, the amount of cost-sharing that
you pay will depend on whether you get the care from network providers or out-of-network
providers. If you get the care from network providers, your share of the costs will usually be
lower than if you get the care from out-of-network providers.
Section 3.2

Getting care when you have an urgent need for care

What is “urgently needed care”?
“Urgently needed care” is a non-emergency, unforeseen medical illness, injury, or condition that
requires immediate medical care. Urgently needed care may be furnished by in-network
providers or by out-of-network providers when network providers are temporarily unavailable or
inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known
condition that you have.
What if you are in the plan’s service area when you have an urgent need for care?
In most situations, if you are in the plan’s service area and you use an out-of-network provider,
you will pay a higher share of the costs for your care. However, if the circumstances are unusual
or extraordinary, and network providers are temporarily unavailable or inaccessible, we will
allow you to get covered services from an out-of-network provider at the lower in-network costsharing amount.
[Plans must insert instructions for how to access in-network urgently needed services (e.g., using
urgent care centers, a provider hotline, etc.)]
What if you are outside the plan’s service area when you have an urgent need for
care?
When you are outside the service area and cannot get care from a network provider, our plan will
cover urgently needed care that you get from any provider at the lower in-network cost-sharing
amount.
[Insert if applicable: Our plan does not cover urgently needed care or any other [insert if plan
covers emergency care outside of the United States: non-emergency] care if you receive the care
outside of the United States. [Modify if overseas care is covered as a supplemental benefit.]]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 4

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

Section 4.1

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

If you have paid more than your share for covered services, or if you have received a bill for the
full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you
have received for covered medical services or drugs) for information about what to do.
Section 4.2

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

[Insert 2015 plan name] covers all medical services that are medically necessary, are listed in the
plan’s Medical Benefits Chart (this chart is in Chapter 4 of this booklet), and are obtained
consistent with plan rules. You are responsible for paying the full cost of services that aren’t
covered by our plan, either because they are not plan covered services, or plan rules were not
followed.
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. If we say we
will not cover your services, you have the right to appeal our decision not to cover your care.
Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)) has more information about what to do if you want a coverage decision from us or
want to appeal a decision we have already made. You may also call Member Services to get
more information about how to do this (phone numbers are printed on the back cover of this
booklet).
For covered services that have a benefit limitation, you pay the full cost of any services you get
after you have used up your benefit for that type of covered service. [Plans should explain
whether paying for costs once a benefit limit has been reached will count toward an out-ofpocket maximum.] You can call Member Services when you want to know how much of your
benefit limit you have already used.

SECTION 5

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

Section 5.1

What is a “clinical research study”?

A clinical research study (also called a “clinical trial”) is a way that doctors and scientists test
new types of medical care, like how well a new cancer drug works. They test new medical care

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

procedures or drugs by asking for volunteers to help with the study. This kind of study is one of
the final stages of a research process that helps doctors and scientists see if a new approach
works and if it is safe.
Not all clinical research studies are open to members of our plan. Medicare [plans that conduct
or cover clinical trials that are not approved by Medicare insert: or our plan] first needs to
approve the research study. If you participate in a study that Medicare [plans that conduct or
cover clinical trials that are not approved by Medicare insert: or our plan] has not approved, you
will be responsible for paying all costs for your participation in the study.
Once Medicare [plans that conduct or cover clinical trials that are not approved by Medicare
insert: or our plan] approves the study, someone who works on the study will contact you to
explain more about the study and see if you meet the requirements set by the scientists who are
running the study. You can participate in the study as long as you meet the requirements for the
study and you have a full understanding and acceptance of what is involved if you participate in
the study.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the
covered services you receive as part of the study. When you are in a clinical research study, you
may stay enrolled in our plan and continue to get the rest of your care (the care that is not related
to the study) through our plan.
If you want to participate in a Medicare-approved clinical research study, you do not need to get
approval from us [plans that do not use PCPs may delete the rest of this sentence] or your PCP.
The providers that deliver your care as part of the clinical research study do not need to be part
of our plan’s network of providers.
Although you do not need to get our plan’s permission to be in a clinical research study, you do
need to tell us before you start participating in a clinical research study. Here is why you
need to tell us:
1.

We can let you know whether the clinical research study is Medicare-approved.

We can tell you what services you will get from clinical research study providers
instead of from our plan.

If you plan on participating in a clinical research study, contact Member Services (phone
numbers are printed on the back cover of this booklet).
Section 5.2

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

Once you join a Medicare-approved clinical research study, you are covered for routine items
and services you receive as part of the study, including:
•

Room and board for a hospital stay that Medicare would pay for even if you weren’t in a
study.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

•

An operation or other medical procedure if it is part of the research study.

•

Treatment of side effects and complications of the new care.

Original Medicare pays most of the cost of the covered services you receive as part of the study.
After Medicare has paid its share of the cost for these services, our plan will also pay for part of
the costs. We will pay the difference between the cost-sharing in Original Medicare and your
cost-sharing as a member of our plan. This means you will pay the same amount for the services
you receive as part of the study as you would if you received these services from our plan.
Here’s an example of how the cost-sharing works: Let’s say that you have a lab test that
costs $100 as part of the research study. Let’s also say that your share of the costs for this
test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits.
In this case, Original Medicare would pay $80 for the test and we would pay another $10.
This means that you would pay $10, which is the same amount you would pay under our
plan’s benefits.
In order for us to pay for our share of the costs, you will need to submit a request for payment.
With your request, you will need to send us a copy of your Medicare Summary Notices or other
documentation that shows what services you received as part of the study and how much you
owe. Please see Chapter 7 for more information about submitting requests for payment.
When you are part of a clinical research study, neither Medicare nor our plan will pay for any
of the following:
•

Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.

•

Items and services the study gives you or any participant for free.

•

Items or services provided only to collect data, and not used in your direct health
care. For example, Medicare would not pay for monthly CT scans done as part of the
study if your medical condition would normally require only one CT scan.

Do you want to know more?
You can get more information about joining a clinical research study by reading the publication
“Medicare and Clinical Research Studies” on the Medicare website (http://www.medicare.gov).
You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

SECTION 6

Rules for getting care covered in a “religious nonmedical health care institution”

Section 6.1

What is a religious non-medical health care institution?

A religious non-medical health care institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a
hospital or a skilled nursing facility is against a member’s religious beliefs, we will instead
provide coverage for care in a religious non-medical health care institution. You may choose to
pursue medical care at any time for any reason. This benefit is provided only for Part A inpatient
services (non-medical health care services). Medicare will only pay for non-medical health care
services provided by religious non-medical health care institutions.
Section 6.2

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

To get care from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical treatment that is “non-excepted.”
•

“Non-excepted” medical care or treatment is any medical care or treatment that is
voluntary and not required by any federal, state, or local law.

•

“Excepted” medical treatment is medical care or treatment that you get that is not
voluntary or is required under federal, state, or local law.

To be covered by our plan, the care you get from a religious non-medical health care institution
must meet the following conditions:
•

The facility providing the care must be certified by Medicare.

•

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

•

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

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
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[Plans must explain whether Medicare Inpatient Hospital coverage limits apply (include a
reference to the benefits chart in Chapter 4) or whether there is unlimited coverage for this
benefit.]

SECTION 7

Rules for ownership of durable medical equipment

Section 7.1

Will you own the durable medical equipment after making a
certain number of payments under our plan?

[Plans that furnish ownership of certain DME items must modify this section to explain the
conditions under which and when specified DME can be owned by the member.]
Durable medical equipment includes items such as oxygen equipment and supplies, wheelchairs,
walkers, and hospital beds ordered by a provider for use in the home. Certain items, such as
prosthetics, are always owned by the member. In this section, we discuss other types of durable
medical equipment that must be rented.
[This first sentence must be inserted even if your plan sometimes allows ownership for items
other than prosthetics] In Original Medicare, people who rent certain types of durable medical
equipment own the equipment after paying copayments for the item for 13 months. As a member
of [insert 2015 plan name], however, you [insert if the plan sometimes allows ownership:
usually] will not acquire ownership of rented durable medical equipment items no matter how
many copayments you make for the item while a member of our plan. [Insert if the plan
sometimes allows ownership for items other than prosthetics: Under certain limited
circumstances we will transfer ownership of the durable medical equipment item. Call Member
Services (phone numbers are printed on the back cover of this booklet) to find out about the
requirements you must meet and the documentation you need to provide.] [Insert if your plan
never transfers ownership (except as noted above, for example, for prosthetics): Even if you
made up to 12 consecutive payments for the durable medical equipment item under Original
Medicare before you joined our plan, you will not acquire ownership no matter how many
copayments you make for the item while a member of our plan.]
What happens to payments you have made for durable medical equipment if you
switch to Original Medicare?
If you switch to Original Medicare after being a member of our plan: If you did not acquire
ownership of the durable medical equipment item while in our plan, you will have to make 13
new consecutive payments for the item while in Original Medicare in order to acquire ownership
of the item. Your previous payments while in our plan do not count toward these 13 consecutive
payments.
If you made payments for the durable medical equipment item under Original Medicare before
you joined our plan, these previous Original Medicare payments also do not count toward the 13
consecutive payments. You will have to make 13 consecutive payments for the item under

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 3.
Using the plan’s coverage for your medical services

Original Medicare in order to acquire ownership. There are no exceptions to this case when you
return to Original Medicare.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Chapter 4. Medical Benefits Chart (what is covered and what you
pay)
SECTION 1
Section 1.1
Section 1.2
Section 1.3

Section 1.4
Section 1.5
Section 1.6
SECTION 2

Understanding your out-of-pocket costs for covered
services ............................................................................................. 55
Types of out-of-pocket costs you may pay for your covered services .......... 55
What is your yearly plan deductible? ............................................................ 55
Our plan [insert if plan has an overall deductible described in Sec. 1.2:
also] has a [insert if plan has an overall deductible described in Sec. 1.2:
separate] deductible for certain types of services from in-network
providers ........................................................................................................ 56
What is the most you will pay for [insert if applicable: Medicare Part A
and Part B] covered medical services? .......................................................... 57
Our plan also limits your out-of-pocket costs for certain types of services .. 58
Our plan does not allow providers to “balance bill” you .............................. 59

Section 2.1
Section 2.2
Section 2.3

Use the Medical Benefits Chart to find out what is covered
for you and how much you will pay ................................................ 60
Your medical benefits and costs as a member of the plan ............................ 60
Extra “optional supplemental” benefits you can buy .................................... 87
Getting care using our plan’s optional visitor/traveler benefit ...................... 87

SECTION 3
Section 3.1

What benefits are not covered by the plan? .................................. 88
Benefits we do not cover (exclusions) .......................................................... 88

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

SECTION 1

Understanding your out-of-pocket costs for covered
services

This chapter focuses on your covered services and what you pay for your medical benefits. It
includes a Medical Benefits Chart that lists your covered services and shows how much you will
pay for each covered service as a member of [insert 2015 plan name]. Later in this chapter, you
can find information about medical services that are not covered. [Insert if applicable: It also
explains limits on certain services.] [If applicable, you may mention other places where benefits,
limitations, and exclusions are described, such as optional additional benefits, or addenda.]
Section 1.1

Types of out-of-pocket costs you may pay for your covered
services

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

The “deductible” is the amount you must pay for medical services before our plan begins
to pay its share. ([Insert if applicable: Section 1.2 tells you more about your yearly plan
deductible.] [Insert if applicable: Section 1.3 tells you more about your yearly
deductibles for certain categories of services.])

•

A “copayment” is the fixed amount you pay each time you receive certain medical
services. You pay a copayment at the time you get the medical service. (The Medical
Benefits Chart in Section 2 tells you more about your copayments.)

•

“Coinsurance” is the percentage you pay of the total cost of certain medical services.
You pay a coinsurance at the time you get the medical service. (The Medical Benefits
Chart in Section 2 tells you more about your coinsurance.)

Some people qualify for State Medicaid programs to help them pay their out-of-pocket costs for
Medicare. (These “Medicare Savings Programs” include the Qualified Medicare Beneficiary
(QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and
Qualified Disabled & Working Individuals (QDWI) programs.) If you are enrolled in one of
these programs, you may still have to pay a copayment for the service, depending on the rules in
your state.
Section 1.2

What is your yearly plan deductible?

[Local or regional PPO plans with no deductibles, delete this section and renumber remaining
subsections in Section 1.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

[Note, RPPOs and local PPO plans that choose to have a deductible are now only permitted to
have a single deductible that applies to both in-network and out-of-network services, see revised
section 422.101(d)(1).]
Your yearly deductible is [insert deductible amount]. This is the amount you have to pay out-ofpocket before we will pay our share for your covered medical services.
Until you have paid the deductible amount, you must pay the full cost for most of your covered
services. (The deductible does not apply to the services that are listed below.) Once you have
paid your deductible, we will begin to pay our share of the costs for covered medical services
and you will pay your share ([insert as applicable: your copayment OR your coinsurance amount
OR your copayment or coinsurance amount]) for the rest of the calendar year.
The deductible does not apply to some services, including certain in-network preventive services.
This means that we will pay our share of the costs for these services even if you haven’t paid
your yearly deductible yet. The deductible does not apply to the following services:
•

[Insert all services not subject to the deductible including all Medicare-covered
preventive services and any other in-network Part A and B services the plan elects to
exempt from the deductible requirement. Plans must specify whether it is in-network
and/or out-of-network services that are exempt from the deductible.] [Note: If a PPO
has a deductible, all out-of-network Part A and B services must be subject to the
deductible with the sole exception that the PPO may elect to waive out-of-network
Medicare-covered zero cost-sharing preventive services from the deductible
requirement.]

Section 1.3

Our plan [insert if plan has an overall deductible described in
Sec. 1.2: also] has a [insert if plan has an overall deductible
described in Sec. 1.2: separate] deductible for certain types of
services from in-network providers

[Plans with service category deductibles: insert this section. If applicable, plans may revise the
text as needed to describe how the service category deductible(s) work with the overall plan
deductible.]
[Plans with a service category deductible that is not based on the calendar year – e.g., a per stay
deductible – should revise this section as needed.]
[Insert if plan has an overall deductible described in Sec. 1.2: In addition to the yearly plan
deductible that applies to all of your covered medical services, we also have a yearly deductible
for certain types of services.]
[Insert if plan does not have an overall deductible and Sec. 1.2 was therefore omitted: We have a
yearly deductible for certain types of services.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

[Insert if plan has one service category deductible: The plan has a yearly deductible amount of
[insert service category deductible] for [insert service category]. Until you have paid the
deductible amount, you must pay the full cost for [insert service category]. Once you have paid
your deductible, we will pay our share of the costs for these services and you will pay your share
([insert as applicable: your copayment OR your coinsurance amount OR your copayment or
coinsurance amount]) for the rest of the calendar year. [Insert if applicable: Both the yearly plan
deductible and the yearly deductible for [insert service category] apply to your covered [insert
service category]. This means that once you meet either the yearly plan deductible or the
deductible for [insert service category], we will begin to pay our share of the costs of your
covered [insert service category].]
[Insert if plan has more than one service category deductible: The plan has a yearly deductible
amount for the following types of services:
•

[Plans should insert a separate bullet for each service category deductible: Our yearly
deductible amount for [insert service category] is [insert service category deductible].
Until you have paid the deductible amount, you must pay the full cost for [insert service
category]. Once you have paid your deductible, we will pay our share of the costs for
these services and you will pay your share ([insert as applicable: your copayment OR
your coinsurance amount OR your copayment or coinsurance amount]) for the rest of the
calendar year. [Insert if applicable: Both the yearly plan deductible for medical services
and the yearly deductible for [insert service category] apply to your covered [insert
service category]. This means that once you meet either the yearly plan deductible for
covered medical services or the deductible for [insert service category], we will begin to
pay our share of the costs of your covered [insert service category].]]

Section 1.4

What is the most you will pay for [insert if applicable:
Medicare Part A and Part B] covered medical services?

Under our plan, there are two different limits on what you have to pay out-of-pocket for covered
medical services:
•

Your in-network maximum out-of-pocket amount is [insert in-network MOOP]. This
is the most you pay during the calendar year for covered [insert as applicable: Medicare
Part A and Part B OR plan] services received from in-network providers. The amounts
you pay for [insert applicable terms: deductibles, copayments, and coinsurance] for
covered services from in-network providers count toward this in-network maximum outof-pocket amount. [Plans with no premium and/or that do not offer Part D may modify
the following sentence as needed] (The amounts you pay for plan premiums, Part D
prescription drugs, and services from out-of-network providers do not count toward your
in-network maximum out-of-pocket amount. [Insert if applicable, revising reference to
asterisk as needed: In addition, amounts you pay for some services do not count toward
your in-network maximum out-of-pocket amount. These services are marked with an
asterisk in the Medical Benefits Chart.]) If you have paid [insert in-network MOOP] for
covered [insert if applicable: Part A and Part B] services from in-network providers, you

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

will not have any out-of-pocket costs for the rest of the year when you see our network
providers. However, you must continue to pay [insert if plan has a premium: your plan
premium and] the Medicare Part B premium (unless your Part B premium is paid for you
by Medicaid or another third party).
•

Your combined maximum out-of-pocket amount is [insert combined MOOP]. This is
the most you pay during the calendar year for covered [insert as applicable: Medicare
Part A and Part B OR plan] services received from both in-network and out-of-network
providers. The amounts you pay for [insert applicable terms: deductibles, copayments,
and coinsurance] for covered services count toward this combined maximum out-ofpocket amount. [Plans with no premium and/or that do not offer Part D may modify the
following sentence as needed] (The amounts you pay for your plan premiums and for
your Part D prescription drugs do not count toward your combined maximum out-ofpocket amount. [Insert if applicable, revising reference to asterisk as needed: In addition,
amounts you pay for some services do not count toward your combined maximum out-ofpocket amount. These services are marked with an asterisk in the Medical Benefits
Chart.]) If you have paid [insert combined MOOP] for covered services, you will have
100% coverage and will not have any out-of-pocket costs for the rest of the year for
covered [insert if applicable: Part A and Part B] services. However, you must continue to
pay [insert if plan has a premium: your plan premium and] the Medicare Part B premium
(unless your Part B premium is paid for you by Medicaid or another third party).

Section 1.5

Our plan also limits your out-of-pocket costs for certain types
of services

[Plans with service category OOP maximums: insert this section.]
[Plans with a service category OOP maximum that is not based on the calendar year – e.g., a
per stay maximum – should revise this section as needed.]
In addition to the in-network and combined maximum out-of-pocket amounts for covered [insert
if applicable: Part A and Part B] services (see Section 1.4 above), we also have a separate
maximum out-of-pocket amount that applies only to certain types of services.
[Insert if plan has one service category MOOP: The plan has a maximum out-of-pocket amount
of [insert service category MOOP] for [insert service category]. Once you have paid [insert
service category MOOP] out-of-pocket for [insert service category], the plan will cover these
services at no cost to you for the rest of the calendar year. [Insert if service category is included
in MOOP described in Section 1.4: Both the maximum out-of-pocket amount for Part A and Part
B medical services and the maximum out-of-pocket amount for [insert service category] apply
to your covered [insert service category]. This means that once you have paid either [insert
MOOP] for Part A and Part B medical services or [insert service category OOP max] for your
[insert service category], the plan will cover your [insert service category] at no cost to you for
the rest of the year.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

[Insert if plan has more than one service category MOOP: The plan has a maximum out-ofpocket amount for the following types of services:
•

[Plans should insert a separate bullet for each service category MOOP: Our maximum
out-of-pocket amount for [insert service category] is [insert service category MOOP].
Once you have paid [insert service category MOOP] out-of-pocket for [insert service
category], the plan will cover these services at no cost to you for the rest of the calendar
year. [Insert if service category is included in MOOP described in Section 1.4: Both the
maximum out-of-pocket amount for Part A and Part B medical services and the
maximum out-of-pocket amount for [insert service category] apply to your covered
[insert service category]. This means that once you have paid either [insert MOOP] for
Part A and Part B medical services or [insert service category OOP max] for your [insert
service category], the plan will cover your [insert service category] at no cost to you for
the rest of the year.]]

Section 1.6

Our plan does not allow providers to “balance bill” you

As a member of [insert 2015 plan name], an important protection for you is that [plans with a
plan-level deductible insert: after you meet any deductibles,] you only have to pay your costsharing amount when you get services covered by our plan. We do not allow providers to add
additional separate charges, called “balance billing.” This protection (that you never pay more
than your cost-sharing amount) applies even if we pay the provider less than the provider charges
for a service and even if there is a dispute and we don’t pay certain provider charges.
Here is how this protection works.
•

If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00), then
you pay only that amount for any covered services from a network provider. You will
generally have higher copays when you obtain care from out-of-network providers.

•

If your cost-sharing is a coinsurance (a percentage of the total charges), then you never
pay more than that percentage. However, your cost depends on which type of provider
you see:
o If you obtain covered services from a network provider, you pay the coinsurance
percentage multiplied by the plan’s reimbursement rate (as determined in the
contract between the provider and the plan).
o If you obtain covered services from an out-of-network provider who participates
with Medicare, you pay the coinsurance percentage multiplied by the Medicare
payment rate for participating providers.
o If you obtain covered services from an out-of-network provider who does not
participate with Medicare, then you pay the coinsurance amount multiplied by the
Medicare payment rate for non-participating providers.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

SECTION 2

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

Section 2.1

Your medical benefits and costs as a member of the plan

The Medical Benefits Chart on the following pages lists the services [insert 2015 plan name]
covers and what you pay out-of-pocket for each service. The services listed in the Medical
Benefits Chart are covered only when the following coverage requirements are met:
•

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

•

Your services (including medical care, services, supplies, and equipment) must be
medically necessary. “Medically necessary” means that the services, supplies, or drugs
are needed for the prevention, diagnosis, or treatment of your medical condition and meet
accepted standards of medical practice.

•

[PPO plans that use prior authorizations insert: Some of the services listed in the
Medical Benefits Chart are covered as in-network services only if your doctor or other
network provider gets approval in advance (sometimes called “prior authorization”) from
[insert 2015 plan name].
o Covered services that need approval in advance to be covered as in-network
services are marked [insert as appropriate: by an asterisk OR by a footnote OR in
bold OR in italics] in the Medical Benefits Chart. [Insert if applicable: In
addition, the following services not listed in the Benefits Chart require approval in
advance: [insert list].]
o You never need approval in advance for out-of-network services from out-ofnetwork providers.
o While you don’t need approval in advance for out-of-network services, you or
your doctor can ask us to make a coverage decision in advance.]

Other important things to know about our coverage:
•

For benefits where your cost-sharing is a coinsurance percentage, the amount you pay
depends on what type of provider you receive the services from:
o If you receive the covered services from a network provider, you pay the
coinsurance percentage multiplied by the plan’s reimbursement rate (as
determined in the contract between the provider and the plan)
o If you receive the covered services from an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for participating providers,

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

o If you receive the covered services from an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers.
•

Like all Medicare health plans, we cover everything that Original Medicare covers. For
some of these benefits, you pay more in our plan than you would in Original Medicare.
For others, you pay less. (If you want to know more about the coverage and costs of
Original Medicare, look in your Medicare & You 2015 Handbook. View it online at
http://www.medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.)

•

We do not charge office visit cost-sharing if the sole purpose of the visit is to obtain
preventive services. [Insert as applicable: However, if you also are treated or monitored
for an existing medical condition during the visit when you receive the preventive
service, a copayment will apply for the care received for the existing medical condition.]

•

Sometimes, Medicare adds coverage under Original Medicare for new services during the
year. If Medicare adds coverage for any services during 2015, either Medicare or our plan
will cover those services.

You will see this apple next to the preventive services in the benefits chart.
[Instructions on completing benefits chart:
•

When preparing this Benefits Chart, please refer to the instructions for completing the
standardized/combined ANOC/EOC.

•

For any benefits for which the plan uses Medicare amounts for member cost-sharing in
their approved bid, the plan may insert the 2014 Medicare amounts; note that these
amounts may change in 2015, and the plan will provide updated rates as soon as
Medicare releases them.

•

For all preventive care and screening test benefit information, plans that cover a richer
benefit than Original Medicare do not need to include given description (unless still
applicable) and may instead describe plan benefit.

•

Optional supplemental benefits are not permitted within the chart; plans that would like
to include information about optional supplemental benefits within the EOC may
describe these benefits within Section 2.2.

•

All plans with networks should clearly indicate for each service applicable the difference
in cost-sharing at network and out-of-network providers and facilities.

•

Plans should clearly indicate which benefits are subject to prior authorization (plans may
use asterisks or similar method).

•

Plans may insert any additional benefits information based on the plan’s approved bid
that is not captured in the benefits chart or in the exclusions section. Additional benefits
should be placed alphabetically in the chart.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

•

Plans must describe any restrictive policies, limitations, or monetary limits that might
impact a beneficiary’s access to services within the chart.
o Plans may add references to the list of exclusions in Sec. 3.1 as appropriate.
o Plans must make it clear for enrollees (in the sections where enrollee cost sharing
is shown) whether their hospital copays or coinsurance apply on the date of
admission and / or on the date of discharge]

Medical Benefits Chart

Services that are covered for you

Abdominal aortic aneurysm screening

A one-time screening ultrasound for people at risk. The plan only
covers this screening if you get a referral for it as a result of your
“Welcome to Medicare” preventive visit.
[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no coinsurance,
copayment, or deductible
for beneficiaries eligible
for this preventive
screening.

Ambulance services

•

Covered ambulance services include fixed wing, rotary wing, and
ground ambulance services, to the nearest appropriate facility
that can provide care only if they are furnished to a member
whose medical condition is such that other means of
transportation are contraindicated (could endanger the person’s
health) or if authorized by the plan.

•

Non-emergency transportation by ambulance is appropriate if it
is documented that the member’s condition is such that other
means of transportation are contraindicated (could endanger the
person’s health) and that transportation by ambulance is
medically required.

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Annual wellness visit

If you’ve had Part B for longer than 12 months, you can get an
annual wellness visit to develop or update a personalized prevention
plan based on your current health and risk factors. This is covered
once every 12 months.
Note: Your first annual wellness visit can’t take place within 12
months of your “Welcome to Medicare” preventive visit. However,
you don’t need to have had a “Welcome to Medicare” visit to be
covered for annual wellness visits after you’ve had Part B for 12
months.

Bone mass measurement

For qualified individuals (generally, this means people at risk of
losing bone mass or at risk of osteoporosis), the following services
are covered every 24 months or more frequently if medically
necessary: procedures to identify bone mass, detect bone loss, or
determine bone quality, including a physician’s interpretation of the
results.
[Also list any additional benefits offered.]

Breast cancer screening (mammograms)

Covered services include:
•
•
•

One baseline mammogram between the ages of 35 and 39
One screening mammogram every 12 months for women age 40
and older
Clinical breast exams once every 24 months

[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no coinsurance,
copayment, or deductible
for the annual wellness
visit.

There is no coinsurance,
copayment, or deductible
for Medicare-covered
bone mass measurement.

There is no coinsurance,
copayment, or deductible
for covered screening
mammograms.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Cardiac rehabilitation services

Comprehensive programs of cardiac rehabilitation services that
include exercise, education, and counseling are covered for members
who meet certain conditions with a doctor’s [insert as appropriate:
referral OR order]. The plan also covers intensive cardiac
rehabilitation programs that are typically more rigorous or more
intense than cardiac rehabilitation programs.
[Also list any additional benefits offered.]

[List copays /
coinsurance / deductible]

Cardiovascular disease risk reduction visit (therapy for
cardiovascular disease)

There is no coinsurance,
copayment, or deductible
for the intensive
behavioral therapy
cardiovascular disease
preventive benefit.

We cover 1 visit per year with your primary care doctor to help
lower your risk for cardiovascular disease. During this visit, your
doctor may discuss aspirin use (if appropriate), check your blood
pressure, and give you tips to make sure you’re eating well.
[Also list any additional benefits offered.]

Cardiovascular disease testing

Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of cardiovascular
disease) once every 5 years (60 months).
[Also list any additional benefits offered.]

Cervical and vaginal cancer screening

Covered services include:
•
•

For all women: Pap tests and pelvic exams are covered once
every 24 months
If you are at high risk of cervical cancer or have had an abnormal
Pap test and are of childbearing age: one Pap test every 12
months

[Also list any additional benefits offered.]

There is no coinsurance,
copayment, or deductible
for cardiovascular
disease testing that is
covered once every 5
years.

There is no coinsurance,
copayment, or deductible
for Medicare-covered
preventive Pap and
pelvic exams.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Chiropractic services

Covered services include:
•

We cover only manual manipulation of the spine to correct
subluxation

[List copays /
coinsurance / deductible]

[Also list any additional benefits offered.]

Colorectal cancer screening

For people 50 and older, the following are covered:
•
•

Flexible sigmoidoscopy (or screening barium enema as an
alternative) every 48 months
Fecal occult blood test, every 12 months

There is no coinsurance,
copayment, or deductible
for a Medicare-covered
colorectal cancer
screening exam.

For people at high risk of colorectal cancer, we cover:
•

Screening colonoscopy (or screening barium enema as an
alternative) every 24 months

For people not at high risk of colorectal cancer, we cover:
•

Screening colonoscopy every 10 years (120 months), but not
within 48 months of a screening sigmoidoscopy

[Also list any additional benefits offered.]
[Include row if applicable. If plan offers dental benefits as optional
supplemental benefits, they should not be included in the chart.
Plans may describe them in Section 2.2 instead.]

[List copays /
coinsurance / deductible]

Dental services

In general, preventive dental services (such as cleaning, routine
dental exams, and dental x-rays) are not covered by Original
Medicare. We cover:
[List any additional benefits offered, such as routine dental care.]

Depression screening

We cover 1 screening for depression per year. The screening must be
done in a primary care setting that can provide follow-up treatment
and referrals.
[Also list any additional benefits offered.]

There is no coinsurance,
copayment, or deductible
for an annual depression
screening visit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Diabetes screening

We cover this screening (includes fasting glucose tests) if you have
any of the following risk factors: high blood pressure (hypertension),
history of abnormal cholesterol and triglyceride levels
(dyslipidemia), obesity, or a history of high blood sugar (glucose).
Tests may also be covered if you meet other requirements, like being
overweight and having a family history of diabetes.
Based on the results of these tests, you may be eligible for up to two
diabetes screenings every 12 months.
[Also list any additional benefits offered.]

Diabetes self-management training, diabetic services and
supplies

[Plans may put items listed under a single bullet in separate bullets
if the plan charges different copays. However, all items in the bullets
must be included.] For all people who have diabetes (insulin and
non-insulin users). Covered services include:
•

•

Supplies to monitor your blood glucose: Blood glucose monitor,
blood glucose test strips, lancet devices and lancets, and glucosecontrol solutions for checking the accuracy of test strips and
monitors
For people with diabetes who have severe diabetic foot disease:
One pair per calendar year of therapeutic custom-molded shoes
(including inserts provided with such shoes) and two additional
pairs of inserts, or one pair of depth shoes and three pairs of
inserts (not including the non-customized removable inserts
provided with such shoes). Coverage includes fitting.
Diabetes self-management training is covered under certain
conditions

[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no coinsurance,
copayment, or
deductible for the
Medicare covered
diabetes screening tests.

There is no coinsurance,
copayment, or deductible
for beneficiaries eligible
for the diabetes selfmanagement training
preventive benefit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Durable medical equipment and related supplies

(For a definition of “durable medical equipment,” see Chapter 12 of
this booklet.)
Covered items include, but are not limited to: wheelchairs, crutches,
hospital bed, IV infusion pump, oxygen equipment, nebulizer, and
walker.
[Plans that do not limit the DME brands and manufacturers that you
will cover insert: We cover all medically necessary durable medical
equipment covered by Original Medicare. If our supplier in your area
does not carry a particular brand or manufacturer, you may ask them
if they can special order it for you.]
[Plans that limit the DME brands and manufacturers that you will
cover insert: With this Evidence of Coverage document, we sent you
[insert 2015 plan name]’s list of durable medical equipment. The list
tells you the brands and manufacturers of durable medical equipment
that we will cover. This most recent list of brands, manufacturers,
and suppliers is also available on our website at [insert URL].
Generally, [insert 2015 plan name] covers any durable medical
equipment covered by Original Medicare from the brands and
manufacturers on this list. We will not cover other brands and
manufacturers unless your doctor or other provider tells us that the
brand is appropriate for your medical needs. However, if you are
new to [insert 2015 plan name] and are using a brand of durable
medical equipment that is not on our list, we will continue to cover
this brand for you for up to 90 days. During this time, you should
talk with your doctor to decide what brand is medically appropriate
for you after this 90-day period. (If you disagree with your doctor,
you can ask him or her to refer you for a second opinion.)
If you (or your provider) don’t agree with the plan’s coverage
decision, you or your provider may file an appeal. You can also file
an appeal if you don’t agree with your provider’s decision about
what product or brand is appropriate for your medical condition. (For
more information about appeals, see Chapter 9, What to do if you
have a problem or complaint (coverage decisions, appeals,
complaints).)]

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Emergency care

Emergency care refers to services that are:
•
•

Furnished by a provider qualified to furnish emergency services,
and
Needed to evaluate or stabilize an emergency medical condition.

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.
[Also identify whether this coverage is within the U.S. or worldwide.]

Health and wellness education programs

[These are programs focused on health conditions such as high
blood pressure, cholesterol, asthma, and special diets. Programs
designed to enrich the health and lifestyles of members include
weight management, fitness, and stress management. Describe the
nature of the programs here.
If this benefit is not applicable, plans should delete this row.]

[List copays /
coinsurance / deductible.
If applicable, explain
that cost-sharing is
waived if member
admitted to hospital.]
[Insert if applicable: If
you receive emergency
care at an out-of-network
hospital and need
inpatient care after your
emergency condition is
stabilized, you must
move to a network
hospital in order to pay
the in-network costsharing amount for the
part of your stay after
you are stabilized. If you
stay at the out-ofnetwork hospital, your
stay will be covered but
you will pay the out-ofnetwork cost-sharing
amount for the part of
your stay after you are
stabilized.]

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Hearing services

Diagnostic hearing and balance evaluations performed by your
[insert as applicable: PCP OR provider] to determine if you need
medical treatment are covered as outpatient care when furnished by a
physician, audiologist, or other qualified provider.
[List any additional benefits offered, such as routine hearing exams,
hearing aids, and evaluations for fitting hearing aids.]

HIV screening

For people who ask for an HIV screening test or who are at increased
risk for HIV infection, we cover:
•

One screening exam every 12 months

For women who are pregnant, we cover:
•

[List copays /
coinsurance / deductible]

There is no coinsurance,
copayment, or deductible
for beneficiaries eligible
for Medicare-covered
preventive HIV
screening.

Up to three screening exams during a pregnancy

[Also list any additional benefits offered.]
Home health agency care

[If needed, plans may revise language related to the doctor
certification requirement.] Prior to receiving home health services, a
doctor must certify that you need home health services and will order
home health services to be provided by a home health agency. You
must be homebound, which means leaving home is a major effort.
Covered services include, but are not limited to:
•

•
•
•

[List copays /
coinsurance / deductible]

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

Hospice care

You may receive care from any Medicare-certified hospice program.
Your hospice doctor can be a network provider or an out-of-network
provider.

When you enroll in a
Medicare-certified
hospice program, your

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Covered services include:
•
•
•

Drugs for symptom control and pain relief
Short-term respite care
Home care

For hospice services and for services that are covered by Medicare
Part A or B and are related to your terminal condition: Original
Medicare (rather than our plan) will pay for your hospice services
and any Part A and Part B services related to your terminal
condition. While you are in the hospice program, your hospice
provider will bill Original Medicare for the services that Original
Medicare pays for.
For services that are covered by Medicare Part A or B and are not
related to your terminal condition: If you need non-emergency, nonurgently needed services that are covered under Medicare Part A or
B and that are not related to your terminal condition, your cost for
these services depends on whether you use a provider in our plan’s
network:
•
•

If you obtain the covered services from a network provider, you
only pay the plan cost-sharing amount for in-network services
If you obtain the covered services from an out-of-network
provider, you pay the plan cost-sharing for out-of-network
services

For services that are covered by [insert 2015 plan name] but are not
covered by Medicare Part A or B: [insert 2015 plan name] will
continue to cover plan-covered services that are not covered under
Part A or B whether or not they are related to your terminal
condition. You pay your plan cost-sharing amount for these services.
Note: If you need non-hospice care (care that is not related to your
terminal condition), you should contact us to arrange the services.
Getting your non-hospice care through our network providers will
lower your share of the costs for the services.
[Insert if applicable, edit as appropriate: Our plan covers hospice
consultation services (one time only) for a terminally ill person who
hasn’t elected the hospice benefit.]

What you must pay
when you get these
services
hospice services and
your Part A and Part B
services related to your
terminal condition are
paid for by Original
Medicare, not [insert
2015 plan name].
[Include information
about cost-sharing for
hospice consultation
services if applicable.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Immunizations

Covered Medicare Part B services include:
•
•
•
•

Pneumonia vaccine
Flu shots, once a year in the fall or winter
Hepatitis B vaccine if you are at high or intermediate risk of
getting Hepatitis B
Other vaccines if you are at risk and they meet Medicare Part B
coverage rules

What you must pay
when you get these
services

There is no coinsurance,
copayment, or deductible
for the pneumonia,
influenza, and Hepatitis
B vaccines.

We also cover some vaccines under our Part D prescription drug
benefit.
[Also list any additional benefits offered.]
Inpatient hospital care

Includes inpatient acute, inpatient rehabilitation, and other types of
inpatient hospital services. Inpatient hospital care starts the day you
are formally admitted to the hospital with a doctor’s order. The day
before you are discharged is your last inpatient day.
[List days covered and any restrictions that apply.] Covered services
include but are not limited to:
•
•
•
•
•
•
•
•
•
•
•
•
•

Semi-private room (or a private room if medically necessary)
Meals including special diets
Regular nursing services
Costs of special care units (such as intensive care or coronary
care units)
Drugs and medications
Lab tests
X-rays and other radiology services
Necessary surgical and medical supplies
Use of appliances, such as wheelchairs
Operating and recovery room costs
Physical, occupational, and speech language therapy
Inpatient substance abuse services
Under certain conditions, the following types of transplants are
covered: corneal, kidney, kidney-pancreatic, heart, liver, lung,
heart/lung, bone marrow, stem cell, and intestinal/multivisceral.
If you need a transplant, we will arrange to have your case

[List all cost-sharing
(deductible,
copayments/coinsurance)
and the period for which
they will be charged. If
cost-sharing is based on
the original Medicare or
a plan-defined benefit
period, include
definition/explanation of
approved benefit period
here. Plans that use peradmission deductible
include: A per admission
deductible is applied
once during the defined
benefit period. [In
addition, if applicable,
explain all other costsharing that is charged
during a benefit
period.]]
[If cost-sharing is not

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

•

reviewed by a Medicare-approved transplant center that will
decide whether you are a candidate for a transplant. [Plans with a
provider network insert: Transplant providers may be local or
outside of the service area. If local transplant providers are
willing to accept the Original Medicare rate, then you can choose
to obtain your transplant services locally or at a distant location
offered by the plan. If [insert 2015 plan name] provides
transplant services at a distant location (outside of the service
area) and you chose to obtain transplants at this distant location,
we will arrange or pay for appropriate lodging and transportation
costs for you and a companion.] [Plans may further define the
specifics of transplant travel coverage.]
Blood - including storage and administration. Coverage of whole
blood and packed red cells begins only with the fourth pint of
blood that you need - you must either pay the costs for the first 3
pints of blood you get in a calendar year or have the blood
donated by you or someone else. All other components of blood
are covered beginning with the first pint used. [Modify as
necessary if the plan begins coverage with an earlier pint.]
Physician services

Note: To be an inpatient, your provider must write an order to admit
you formally as an inpatient of the hospital. Even if you stay in the
hospital overnight, you might still be considered an “outpatient.” If
you are not sure if you are an inpatient or an outpatient, you should
ask the hospital staff.
You can also find more information in a Medicare fact sheet called
“Are You a Hospital Inpatient or Outpatient? If You Have Medicare
– Ask!” This fact sheet is available on the Web at
http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by
calling 1-800-MEDICARE (1-800-633-4227). TTY users call
1-877-486-2048. You can call these numbers for free, 24 hours a
day, 7 days a week.

What you must pay
when you get these
services
based on the original
Medicare or plandefined benefit period,
explain here when the
cost-sharing will be
applied. If it is charged
on a per admission basis,
include: A deductible
and/or other cost-sharing
is charged for each
inpatient stay.]
[If inpatient costsharing varies based on
hospital tier, enter that
cost-sharing in the data
entry fields.]
If you get [insert if
applicable: authorized]
inpatient care at an outof-network hospital
after your emergency
condition is stabilized,
your cost is the [insert
if applicable: highest]
cost-sharing you would
pay at a network
hospital.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Inpatient mental health care

•

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

What you must pay
when you get these
services
[List all cost-sharing
(deductible,
copayments/coinsurance)
and the period for which
they will be charged. If
cost-sharing is based on
the original Medicare or
a plan-defined benefit
period, include
definition/explanation of
approved benefit period
here. Plans that use peradmission deductible
include: A per admission
deductible is applied
once during the defined
benefit period. [In
addition, if applicable,
explain all other costsharing that is charged
during a benefit
period.]]
[If cost-sharing is not
based on the original
Medicare or plandefined benefit period,
explain here when the
cost-sharing will be
applied. If it is charged
on a per admission basis,
include: A deductible
and/or other cost-sharing
is charged for each
inpatient stay.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Inpatient services covered during a non-covered inpatient stay

[Plans with no day limitations on a plan’s hospital or SNF coverage
may modify or delete this row as appropriate.]
If you have exhausted your inpatient benefits or if the inpatient stay
is not reasonable and necessary, we will not cover your inpatient
stay. However, in some cases, we will cover certain services you
receive while you are in the hospital or the skilled nursing facility
(SNF). Covered services include, but are not limited to:
•
•
•
•
•
•

•

Physician services
Diagnostic tests (like lab tests)
X-ray, radium, and isotope therapy including technician materials
and services
Surgical dressings
Splints, casts and other devices used to reduce fractures and
dislocations
Prosthetics and orthotics devices (other than dental) that replace
all or part of an internal body organ (including contiguous
tissue), or all or part of the function of a permanently inoperative
or malfunctioning internal body organ, including replacement or
repairs of such devices
Leg, arm, back, and neck braces; trusses, and artificial legs, arms,
and eyes including adjustments, repairs, and replacements
required because of breakage, wear, loss, or a change in the
patient’s physical condition
Physical therapy, speech therapy, and occupational therapy

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Medical nutrition therapy

This benefit is for people with diabetes, renal (kidney) disease (but
not on dialysis), or after a kidney transplant when [insert as
appropriate: referred OR ordered] by your doctor.
We cover 3 hours of one-on-one counseling services during your
first year that you receive medical nutrition therapy services under
Medicare (this includes our plan, any other Medicare Advantage
plan, or Original Medicare), and 2 hours each year after that. If your
condition, treatment, or diagnosis changes, you may be able to
receive more hours of treatment with a physician’s [insert as
appropriate: referral OR order]. A physician must prescribe these
services and renew their [insert as appropriate: referral OR order]
yearly if your treatment is needed into the next calendar year.
[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no coinsurance,
copayment, or
deductible for
beneficiaries eligible for
Medicare-covered
medical nutrition
therapy services.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Medicare Part B prescription drugs

These drugs are covered under Part B of Original Medicare.
Members of our plan receive coverage for these drugs through our
plan. Covered drugs include:
•
•
•
•
•
•
•
•

•

Drugs that usually aren’t self-administered by the patient and are
injected or infused while you are getting physician, hospital
outpatient, or ambulatory surgical center services
Drugs you take using durable medical equipment (such as
nebulizers) that were authorized by the plan
Clotting factors you give yourself by injection if you have
hemophilia
Immunosuppressive Drugs, if you were enrolled in Medicare Part
A at the time of the organ transplant
Injectable osteoporosis drugs, if you are homebound, have a bone
fracture that a doctor certifies was related to post-menopausal
osteoporosis, and cannot self-administer the drug
Antigens
Certain oral anti-cancer drugs and anti-nausea drugs
Certain drugs for home dialysis, including heparin, the antidote
for heparin when medically necessary, topical anesthetics, and
erythropoiesis-stimulating agents [plans may delete any of the
following drugs that are not covered under the plan] (such as
Epogen, Procrit, Epoetin Alfa, Aranesp, or Darbepoetin
Alfa)
Intravenous Immune Globulin for the home treatment of primary
immune deficiency diseases

Chapter 5 explains the Part D prescription drug benefit, including
rules you must follow to have prescriptions covered. What you pay
for your Part D prescription drugs through our plan is explained in
Chapter 6.

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Obesity screening and therapy to promote sustained
weight loss

If you have a body mass index of 30 or more, we cover intensive
counseling to help you lose weight. This counseling is covered if you
get it in a primary care setting, where it can be coordinated with your
comprehensive prevention plan. Talk to your primary care doctor or
practitioner to find out more.
[Also list any additional benefits offered.]
Outpatient diagnostic tests and therapeutic services and
supplies

Covered services include, but are not limited to:
•
•

•
•
•
•

•

X-rays
Radiation (radium and isotope) therapy including technician
materials and supplies [List separately any services for which a
separate copay/coinsurance applies over and above the outpatient
radiation therapy copay/coinsurance.]
Surgical supplies, such as dressings
Splints, casts and other devices used to reduce fractures and
dislocations
Laboratory tests
Blood. Coverage begins with the fourth pint of blood that you
need – you must either pay the costs for the first 3 pints of blood
you get in a calendar year or have the blood donated by you or
someone else. [Modify as necessary if the plan begins coverage
with an earlier pint.] Coverage of storage and administration
begins with the first pint of blood that you need.
Other outpatient diagnostic tests [Plans can include other covered
tests as appropriate.]

What you must pay
when you get these
services

There is no coinsurance,
copayment, or deductible
for preventive obesity
screening and therapy.

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Outpatient hospital services

We cover medically-necessary services you get in the outpatient
department of a hospital for diagnosis or treatment of an illness or
injury.
Covered services include, but are not limited to:
•
•
•
•
•
•
•

Services in an emergency department or outpatient clinic, such as
observation services or outpatient surgery
Laboratory and diagnostic tests billed by the hospital
Mental health care, including care in a partial-hospitalization
program, if a doctor certifies that inpatient treatment would be
required without it
X-rays and other radiology services billed by the hospital
Medical supplies such as splints and casts
Certain screenings and preventive services
Certain drugs and biologicals that you can’t give yourself

Note: Unless the provider has written an order to admit you as an
inpatient to the hospital, you are an outpatient and pay the costsharing amounts for outpatient hospital services. Even if you stay in
the hospital overnight, you might still be considered an “outpatient.”
If you are not sure if you are an outpatient, you should ask the
hospital staff.
You can also find more information in a Medicare fact sheet called
“Are You a Hospital Inpatient or Outpatient? If You Have Medicare
– Ask!” This fact sheet is available on the Web at
http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by
calling 1-800-MEDICARE (1-800-633-4227). TTY users call
1-877-486-2048. You can call these numbers for free, 24 hours a
day, 7 days a week.
[Also list any additional benefits offered.]

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Outpatient mental health care

Covered services include:
Mental health services provided by a state-licensed psychiatrist or
doctor, clinical psychologist, clinical social worker, clinical nurse
specialist, nurse practitioner, physician assistant, or other Medicarequalified mental health care professional as allowed under applicable
state laws.
[Also list any additional benefits offered.]

[List copays /
coinsurance / deductible]

Outpatient rehabilitation services

Covered services include: physical therapy, occupational therapy,
and speech language therapy.
Outpatient rehabilitation services are provided in various outpatient
settings, such as hospital outpatient departments, independent
therapist offices, and Comprehensive Outpatient Rehabilitation
Facilities (CORFs).

[List copays /
coinsurance / deductible]

Outpatient substance abuse services

[List copays /
coinsurance / deductible]

[Describe the plan’s benefits for outpatient substance abuse
services.]
Outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers

[List copays /
coinsurance / deductible]

Note: If you are having surgery in a hospital facility, you should
check with your provider about whether you will be an inpatient or
outpatient. Unless the provider writes an order to admit you as an
inpatient to the hospital, you are an outpatient and pay the costsharing amounts for outpatient surgery. Even if you stay in the
hospital overnight, you might still be considered an “outpatient.”
Partial hospitalization services

“Partial hospitalization” is a structured program of active psychiatric
treatment provided in a hospital outpatient setting or by a community
mental health center, that is more intense than the care received in
your doctor’s or therapist’s office and is an alternative to inpatient
hospitalization.

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Physician/Practitioner services, including doctor’s office visits

Covered services include:
•
•
•
•

•
•

Medically-necessary medical care or surgery services furnished
in a physician’s office, certified ambulatory surgical center,
hospital outpatient department, or any other location
Consultation, diagnosis, and treatment by a specialist
Basic hearing and balance exams performed by your [insert as
applicable: PCP OR specialist], if your doctor orders it to see if
you need medical treatment.
[Insert if the plan has a service area and providers/locations that
qualify for telehealth services under the Medicare requirements:
Certain telehealth services including consultation, diagnosis, and
treatment by a physician or practitioner for patients in certain
rural areas or other locations approved by Medicare]
Second opinion [Insert if appropriate: by another network
provider] prior to surgery
Non-routine dental care (covered services are limited to surgery
of the jaw or related structures, setting fractures of the jaw or
facial bones, extraction of teeth to prepare the jaw for radiation
treatments of neoplastic cancer disease, or services that would be
covered when provided by a physician)

[List copays /
coinsurance / deductible]

[Also list any additional benefits offered.]
Podiatry services

Covered services include:
•
•

Diagnosis and the medical or surgical treatment of injuries and
diseases of the feet (such as hammer toe or heel spurs).
Routine foot care for members with certain medical conditions
affecting the lower limbs

[Also list any additional benefits offered.]

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Prostate cancer screening exams

For men age 50 and older, covered services include the following once every 12 months:
•
•

What you must pay
when you get these
services

There is no coinsurance,
copayment, or deductible
for an annual PSA test.

Digital rectal exam
Prostate Specific Antigen (PSA) test

[Also list any additional benefits offered.]
Prosthetic devices and related supplies

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

[List copays /
coinsurance / deductible]

Pulmonary rehabilitation services

Comprehensive programs of pulmonary rehabilitation are covered
for members who have moderate to very severe chronic obstructive
pulmonary disease (COPD) and [insert as appropriate: a referral OR
an order] for pulmonary rehabilitation from the doctor treating the
chronic respiratory disease.
[Also list any additional benefits offered.]

Screening and counseling to reduce alcohol misuse

We cover one alcohol misuse screening for adults with Medicare
(including pregnant women) who misuse alcohol, but aren’t alcohol
dependent.
If you screen positive for alcohol misuse, you can get up to 4 brief
face-to-face counseling sessions per year (if you’re competent and
alert during counseling) provided by a qualified primary care doctor
or practitioner in a primary care setting.
[Also list any additional benefits offered.]

[List copays /
coinsurance / deductible]

There is no coinsurance,
copayment, or deductible
for the Medicare-covered
screening and counseling
to reduce alcohol misuse
preventive benefit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Screening for sexually transmitted infections (STIs) and
counseling to prevent STIs

We cover sexually transmitted infection (STI) screenings for
chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings
are covered for pregnant women and for certain people who are at
increased risk for an STI when the tests are ordered by a primary
care provider. We cover these tests once every 12 months or at
certain times during pregnancy.
We also cover up to 2 individual 20 to 30 minute, face-to-face highintensity behavioral counseling sessions each year for sexually active
adults at increased risk for STIs. We will only cover these counseling
sessions as a preventive service if they are provided by a primary
care provider and take place in a primary care setting, such as a
doctor’s office.
[Also list any additional benefits offered.]

What you must pay
when you get these
services

There is no coinsurance,
copayment, or deductible
for the Medicare-covered
screening for STIs and
counseling to prevent
STIs preventive benefit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Services to treat kidney disease and conditions

Covered services include:
•

•
•
•
•
•

Kidney disease education services to teach kidney care and help
members make informed decisions about their care. For members
with stage IV chronic kidney disease when referred by their
doctor, we cover up to six sessions of kidney disease education
services per lifetime.
Outpatient dialysis treatments (including dialysis treatments
when temporarily out of the service area, as explained in Chapter
3)
Inpatient dialysis treatments (if you are admitted as an inpatient
to a hospital for special care)
Self-dialysis training (includes training for you and anyone
helping you with your home dialysis treatments)
Home dialysis equipment and supplies
Certain home support services (such as, when necessary, visits by
trained dialysis workers to check on your home dialysis, to help
in emergencies, and check your dialysis equipment and water
supply)

Certain drugs for dialysis are covered under your Medicare Part B
drug benefit. For information about coverage for Part B Drugs,
please go to the section below, “Medicare Part B prescription drugs.”

[List copays /
coinsurance / deductible]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Skilled nursing facility (SNF) care

(For a definition of “skilled nursing facility care,” see Chapter 12 of
this booklet. Skilled nursing facilities are sometimes called “SNFs.”)
[List days covered and any restrictions that apply, including whether
any prior hospital stay is required.] Covered services include but are
not limited to:
•
•
•
•
•
•

•
•
•
•
•

Semiprivate room (or a private room if medically necessary)
Meals, including special diets
Skilled nursing services
Physical therapy, occupational therapy, and speech therapy
Drugs administered to you as part of your plan of care (This
includes substances that are naturally present in the body, such as
blood clotting factors.)
Blood - including storage and administration. Coverage of whole
blood and packed red cells begins only with the fourth pint of
blood that you need - you must either pay the costs for the first 3
pints of blood you get in a calendar year or have the blood
donated by you or someone else. All other components of blood
are covered beginning with the first pint used. [Modify as
necessary if the plan begins coverage with an earlier pint.]
Medical and surgical supplies ordinarily provided by SNFs
Laboratory tests ordinarily provided by SNFs
X-rays and other radiology services ordinarily provided by SNFs
Use of appliances such as wheelchairs ordinarily provided by
SNFs
Physician/Practitioner services

Generally, you will get your SNF care from network facilities.
However, under certain conditions listed below, you may be able to
pay in-network cost-sharing for a facility that isn’t a network
provider, if the facility accepts our plan’s amounts for payment.
•
•

A nursing home or continuing care retirement community where
you were living right before you went to the hospital (as long as
it provides skilled nursing facility care).
A SNF where your spouse is living at the time you leave the
hospital.

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay
when you get these
services

Smoking and tobacco use cessation (counseling to stop
smoking or tobacco use)

If you use tobacco, but do not have signs or symptoms of tobaccorelated disease: We cover two counseling quit attempts within a 12month period as a preventive service with no cost to you. Each
counseling attempt includes up to four face-to-face visits.
If you use tobacco and have been diagnosed with a tobacco-related
disease or are taking medicine that may be affected by tobacco: We
cover cessation counseling services. We cover two counseling quit
attempts within a 12-month period, however, you will pay the
applicable inpatient or outpatient cost-sharing. Each counseling
attempt includes up to four face-to-face visits.
[Also list any additional benefits offered.]

There is no coinsurance,
copayment, or deductible
for the Medicare-covered
smoking and tobacco use
cessation preventive
benefits.

]

Urgently needed care

Urgently needed care is care provided to treat a non-emergency,
unforeseen medical illness, injury, or condition that requires
immediate medical care. Urgently needed care may be furnished by
in-network providers or by out-of-network providers when network
providers are temporarily unavailable or inaccessible.
[Include in-network benefits. Also identify whether this coverage is
within the U.S. or world-wide.]

[List copays /
coinsurance / deductible.
Plans should include
different copayments for
contracted urgent care
centers, if applicable.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

Vision care

Covered services include:
•

•

What you must pay
when you get these
services

[List copays /
coinsurance / deductible]

Outpatient physician services for the diagnosis and treatment of
diseases and injuries of the eye, including treatment for agerelated macular degeneration. Original Medicare doesn’t cover
routine eye exams (eye refractions) for eyeglasses/contacts.
For people who are at high risk of glaucoma, such as people with
a family history of glaucoma, people with diabetes, and AfricanAmericans who are age 50 and older: glaucoma screening once
per year.
[Adapt this description if the plan offers more than is covered by
Original Medicare.] One pair of eyeglasses or contact lenses
after each cataract surgery that includes insertion of an
intraocular lens. (If you have two separate cataract operations,
you cannot reserve the benefit after the first surgery and purchase
two eyeglasses after the second surgery.) Corrective
lenses/frames (and replacements) needed after a cataract removal
without a lens implant.

[Also list any additional benefits offered, such as supplemental
vision exams or glasses. If the additional vision benefits are optional
supplemental benefits, they should not be included in the benefits
chart; they should be described within Section 2.2.]

“Welcome to Medicare” Preventive Visit

The plan covers the one-time “Welcome to Medicare” preventive
visit. The visit includes a review of your health, as well as education
and counseling about the preventive services you need (including
certain screenings and shots), and referrals for other care if needed.
Important: We cover the “Welcome to Medicare” preventive visit
only within the first 12 months you have Medicare Part B. When you
make your appointment, let your doctor’s office know you would
like to schedule your “Welcome to Medicare” preventive visit.

There is no coinsurance,
copayment, or deductible
for the “Welcome to
Medicare” preventive
visit.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

Section 2.2

Extra “optional supplemental” benefits you can buy

[Include this section if you offer optional supplemental benefits in the plan and describe benefits
below. You may include this section either in the EOC or as an insert to the EOC.]
Our Plan offers some extra benefits that are not covered by Original Medicare and not included
in your benefits package as a plan member. These extra benefits are called “Optional
Supplemental Benefits.” If you want these optional supplemental benefits, you must sign up for
them [insert if applicable: and you may have to pay an additional premium for them]. The
optional supplemental benefits described in [insert as applicable: this section OR the enclosed
insert] are subject to the same appeals process as any other benefits.
[Insert plan specific optional benefits, premiums, deductible, copays and coinsurance and rules
using a chart like the Benefits Chart above. Insert plan specific procedures on how to elect
optional supplemental coverage, including application process and effective dates and on how to
discontinue optional supplemental coverage, including refund of premiums. Also insert any
restrictions on members’ re-applying for optional supplemental coverage (e.g., must wait until
next annual enrollment period).]
Section 2.3

Getting care using our plan’s optional visitor/traveler benefit

[If your plan offers a visitor/traveler program to members who are out of your service area,
insert this section, adapting and expanding the following paragraphs as needed to describe the
traveler benefits and rules related to receiving the out-of-area coverage. If you allow extended
periods of enrollment out-of-area per the exception in 42 CFR 422.74(b)(4)(iii) (for more than
six months up to 12 months) also explain that here based on the language suggested below.
When you are continuously absent from our plan’s service area for more than six months, we
usually must disenroll you from our plan. However, we offer as a supplemental benefit a
visitor/traveler program [specify areas where the visitor/traveler program is being offered],
which will allow you to remain enrolled in our plan when you are outside of our service area for
less than 12 months. This program is available to all [insert 2015 plan name] members who are
temporarily in the visitor/traveler area. Under our visitor/traveler program you may receive all
plan covered services at in-network cost-sharing. Please contact the plan for assistance in
locating a provider when using the visitor/traveler benefit.
If you are in the visitor/traveler area, you can stay enrolled in our plan for up to 12 months. If
you have not returned to the plan’s service area within 12 months, you will be disenrolled from
the plan.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

SECTION 3

What benefits are not covered by the plan?

Section 3.1

Benefits we do not cover (exclusions)

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

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

•

Experimental medical and surgical procedures, equipment and medications, unless
covered by Original Medicare or under a Medicare-approved clinical research study or by
our plan. (See Chapter 3, Section 5 for more information on clinical research studies.)
Experimental procedures and items are those items and procedures determined by our
plan and Original Medicare to not be generally accepted by the medical community.

•

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

•

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

•

Private duty nurses.

•

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

•

Full-time nursing care in your home.

•

Custodial care is care provided in a nursing home, hospice, or other facility setting when
you do not require skilled medical care or skilled nursing care. Custodial care is personal
care that does not require the continuing attention of trained medical or paramedical
personnel, such as care that helps you with activities of daily living, such as bathing or
dressing.

•

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

•

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

•

Meals delivered to your home.

•

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

•

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

•

Routine dental care, such as cleanings, fillings or dentures. However, non-routine dental
care required to treat illness or injury may be covered as inpatient or outpatient care.

•

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

•

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

•

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

•

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

•

Routine hearing exams, hearing aids, or exams to fit hearing aids.

•

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

•

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

•

Acupuncture.

•

Naturopath services (uses natural or alternative treatments).

•

Services provided to veterans in Veterans Affairs (VA) facilities. However, when
emergency services are received at VA hospital and the VA cost-sharing is more than the

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 4.
Medical Benefits Chart (what is covered and what you pay)

cost-sharing under our plan, we will reimburse veterans for the difference. Members are
still responsible for our cost-sharing amounts.
The plan will not cover the excluded services listed above. Even if you receive the services at an
emergency facility, the excluded services are still not covered.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Using the plan’s coverage for your Part D prescription drugs

Chapter 5. Using the plan’s coverage for your Part D prescription
drugs
SECTION 1
Section 1.1
Section 1.2

Introduction ...................................................................................... 93
This chapter describes your coverage for Part D drugs ................................. 93
Basic rules for the plan’s Part D drug coverage ............................................ 94

SECTION 2

Fill your prescription at a network pharmacy [insert if
applicable: or through the plan’s mail-order service] ................... 94
To have your prescription covered, use a network pharmacy ....................... 94
Finding network pharmacies ......................................................................... 94
Using the plan’s mail-order services ............................................................. 96
How can you get a long-term supply of drugs?............................................. 97
When can you use a pharmacy that is not in the plan’s network?................. 98

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” .......................... 99
The “Drug List” tells which Part D drugs are covered.................................. 99
There are [insert number of tiers] “cost-sharing tiers” for drugs on the
Drug List...................................................................................................... 100
How can you find out if a specific drug is on the Drug List? ..................... 100

SECTION 4
Section 4.1
Section 4.2
Section 4.3

There are restrictions on coverage for some drugs .................... 101
Why do some drugs have restrictions? ........................................................ 101
What kinds of restrictions? .......................................................................... 101
Do any of these restrictions apply to your drugs? ....................................... 102

SECTION 5

What if one of your drugs is not covered in the way you’d
like it to be covered? ...................................................................... 103
There are things you can do if your drug is not covered in the way you’d
like it to be covered ..................................................................................... 103
What can you do if your drug is not on the Drug List or if the drug is
restricted in some way? ............................................................................... 104
What can you do if your drug is in a cost-sharing tier you think is too
high? ............................................................................................................ 106

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? ............. 107
The Drug List can change during the year .................................................. 107
What happens if coverage changes for a drug you are taking? ................... 108

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
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? ..................... 109
Types of drugs we do not cover .................................................................. 109

SECTION 8

Show your plan membership card when you fill a
prescription..................................................................................... 110
Show your membership card ....................................................................... 110
What if you don’t have your membership card with you? .......................... 111

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

SECTION 10
Section 10.1
Section 10.2

Part D drug coverage in special situations .................................. 111
What if you’re in a hospital or a skilled nursing facility for a stay that is
covered by the plan? .................................................................................... 111
What if you’re a resident in a long-term care (LTC) facility? .................... 111
What if you’re also getting drug coverage from an employer or retiree
group plan? .................................................................................................. 112
Programs on drug safety and managing medications ................ 113
Programs to help members use drugs safely ............................................... 113
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...................... 113

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Using the plan’s coverage for your Part D prescription drugs

Did you know there are programs to help people pay for their drugs?
[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 6, What you pay for your Part D prescription drugs).
In addition to your coverage for Part D drugs, [insert 2015 plan name] also covers some drugs
under the plan’s medical benefits:
•

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

•

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. Chapter 4 (Medical Benefits Chart, what is
covered and what you pay) tells about your benefits and costs for Part B drugs.

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
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 5.
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 (LTC) 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 5.
Using the plan’s coverage for your Part D prescription drugs

Section 2.3

Using the plan’s mail-order services

[Omit if the plan does not offer mail-order services.]
[Include the following information only if your mail-order service is limited to a subset of all
formulary drugs, adapting terminology as needed: For certain kinds of drugs, you can use the
plan’s network mail-order services. 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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Using the plan’s coverage for your Part D prescription drugs

[Option 2Ai: Plans that have an auto-delivery program but have not received an exception from
CMS]. If you sign up for our optional automatic delivery program, the mail order [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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Using the plan’s coverage for your Part D prescription drugs

“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.)
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.)

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 5.
Using the plan’s coverage for your Part D prescription drugs

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 7, Section 2.1 explains how to ask the plan to
pay you back.)

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).]

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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.

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 6 (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.]

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SECTION 4

There are restrictions on coverage for some drugs

Section 4.1

Why do some drugs have restrictions?

101

For certain prescription drugs, special rules restrict how and when the plan covers them. A team
of doctors and pharmacists developed these rules to help our members use drugs in the most
effective ways. These special rules also help control overall drug costs, which keeps your drug
coverage more affordable.
In general, our rules encourage you 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 9, Section 6.2 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.)

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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.
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 9, Section 6.2 for information about asking
for exceptions.)

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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
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.

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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.
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.

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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 supply limit
(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 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 supply limit
(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).

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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.
[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 9, Section 6.4 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.

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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 9, Section 6.4 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)].]

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.

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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.

•

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 9 (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.

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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 9, Section 6.5 in this booklet.)
Here are three general rules about drugs that Medicare drug plans will not cover under Part D:
•

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

•

Our plan 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.

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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.

110

[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 6, Section 7 of this booklet.)]
[Insert if plan offers coverage for any drugs excluded under Part D: In addition, if you are
receiving “Extra Help” from Medicare to pay for your prescriptions, the “Extra Help”
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
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.

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

If you don’t have your plan membership card with you when you fill your prescription, ask the
pharmacy to call the plan to get the necessary information.
If the pharmacy is not able to get the necessary information, you may have to pay the full cost
of the prescription when you pick it up. (You can then ask us to reimburse you for our share.
See Chapter 7, Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 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 the plan?

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we
will generally cover the cost of your prescription drugs during your stay. Once you leave the
hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of
our rules for coverage. See the previous parts of this section that tell about the rules for getting
drug coverage. Chapter 6 (What you pay for your Part D prescription drugs) gives more
information about drug coverage and what you pay.
Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a
Special Enrollment Period. During this time period, you can switch plans or change your
coverage. (Chapter 10, 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

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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 9, Section 6.4 tells what
to do.
Section 9.3

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

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

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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.
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

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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).

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Chapter 6. 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
SECTION 6

Section 6.1

Introduction .................................................................................... 117
Use this chapter together with other materials that explain your drug
coverage....................................................................................................... 117
Types of out-of-pocket costs you may pay for covered drugs .................... 118
What you pay for a drug depends on which “drug payment
stage” you are in when you get the drug ..................................... 118
What are the drug payment stages for [insert 2015 plan name] members? 118
We send you reports that explain payments for your drugs
and which payment stage you are in ............................................ 120
We send you a monthly report called the “Part D Explanation of
Benefits” (the “Part D EOB”) ...................................................................... 120
Help us keep our information about your drug payments up to date .......... 120
During the Deductible Stage, you pay the full cost of your
[insert drug tiers if applicable] drugs ........................................... 121
You stay in the Deductible Stage until you have paid $[insert deductible
amount] for your [insert drug tiers if applicable] drugs............................. 121
During the Initial Coverage Stage, the plan pays its share of
your drug costs and you pay your share ..................................... 122
What you pay for a drug depends on the drug and where you fill your
prescription .................................................................................................. 122
A table that shows your costs for a one-month supply of a drug ................ 123
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 ....................................... 124
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 ....................................... 125
You stay in the Initial Coverage Stage until your [insert as applicable:
total drug costs for the year reach $[insert initial coverage limit] OR outof-pocket costs for the year reach $ [insert 2015 out-of-pocket threshold] 127
How Medicare calculates your out-of-pocket costs for prescription drugs. 128
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] ..................................................... 131
You stay in the Coverage Gap Stage until your out-of-pocket costs reach
$ [insert 2015 out-of-pocket threshold] ...................................................... 131

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Section 6.2
SECTION 7
Section 7.1

116

How Medicare calculates your out-of-pocket costs for prescription drugs. 132
During the Catastrophic Coverage Stage, the plan pays
most of the cost for your drugs .................................................... 134
Once you are in the Catastrophic Coverage Stage, you will stay in this
stage for the rest of the year ........................................................................ 134

SECTION 8
Section 8.1

Additional benefits information..................................................... 134
Our plan offers additional benefits .............................................................. 134

SECTION 9

What you pay for vaccinations covered by Part D depends
on how and where you get them ................................................... 135
Our plan has separate coverage for the Part D vaccine medication itself
and for the cost of giving you the vaccination shot ..................................... 135
You may want to call us at Member Services before you get a vaccination137

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”? ......... 137
What is the Part D “late enrollment penalty”? ............................................ 137
How much is the Part D late enrollment penalty? ....................................... 138
In some situations, you can enroll late and not have to pay the penalty ..... 138
What can you do if you disagree about your late enrollment penalty? ....... 139

SECTION 11

Do you have to pay an extra Part D amount because of your
income?........................................................................................... 140
Who pays an extra Part D amount because of income? .............................. 140
How much is the extra Part D amount? ....................................................... 141
What can you do if you disagree about paying an extra Part D amount? ... 141
What happens if you do not pay the extra Part D amount? ......................... 142

Section 11.1
Section 11.2
Section 11.3
Section 11.4

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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 5, 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.
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.

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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 5 of this booklet. Chapter 5 gives the details about your prescription drug
coverage, including rules you need to follow when you get your covered drugs. Chapter 5
also tells which types of prescription drugs are not covered by our plan.

•

The plan’s [insert if applicable: Provider/] Pharmacy Directory. In most situations you
must use a network pharmacy to get your covered drugs (see Chapter 5 for the details).
The [insert if applicable: Provider/] 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 longterm supply of a drug (such as filling a prescription for a three-month’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.]

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Stage 1

Stage 2

Stage 3

Stage 4

Yearly Deductible
Stage

Initial Coverage Stage

Coverage Gap Stage

Catastrophic
Coverage Stage

[If plan has a deductible
for all tiers insert: You
begin in this payment
stage when you fill your
first prescription of the
year.]

[Insert if plan has no
deductible: You begin in
this stage when you fill
your first prescription of
the year.]

[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).

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 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 initial coverage
limit]. OR “out-ofpocket costs” (your
payments) reach $
[insert 2015 out-ofpocket 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.)

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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 “Part D 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 7, Section 2 of this booklet.) Here are some types of

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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.
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 an Part D Explanation of
Benefits (a Part D 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.]

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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 tier] drugs. You must pay the full cost of your
[insert applicable drug tier] 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:

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•

[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]

•

[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 5
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 cost-sharing 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 5, Section 2.5 for information about when we will cover a prescription
filled at an out-of-network pharmacy.

[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

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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].”]
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
costsharing
(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 5 for
details.) (up to a
[insert number of
days]-day supply)

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

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Cost-Sharing
Tier 2
([insert
description])

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Cost-Sharing
Tier 3
([insert
description])

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Cost-Sharing
Tier 4
([insert
description])

[Insert
copay/
coinsurance]

[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.

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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
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 5,
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.

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126

[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.

[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:
Standard retail
cost-sharing (innetwork)
([insert if applicable:
up to a] [insert
number of days]-day
supply)

Preferred retail
cost-sharing (innetwork)

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]

Tier

([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)

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Section 5.5

127

You stay in the Initial Coverage Stage until your [insert as
applicable: total drug costs for the year reach $[insert 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:
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 Part D Explanation of Benefits (Part D 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 for your
drugs 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.

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

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These payments are included in your out-of-pocket costs
When you add up your out-of-pocket costs, you can include the payments listed below (as
long as they are for Part D covered drugs and you followed the rules for drug coverage that
are explained in Chapter 5 of this booklet):
• The amount you pay for drugs when you are in any of the following drug payment
stages:
o

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

The Initial Coverage 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 a 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-ofpocket threshold] in out-of-pocket costs within the calendar year, you will move from the
Initial Coverage Stage to the Catastrophic Coverage Stage.

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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 Initial
Coverage Stage and have moved on to the Catastrophic Coverage Stage.

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•

131

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 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 6.
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Section 6.2

132

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.

[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 a
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.

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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 Part D 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]
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134

• 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.]

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.]

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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. We also cover vaccines that are
considered medical benefits. You can find out about coverage of these vaccines by going to the
Medical Benefits Chart in Chapter 4, Section 2.1.
There are two parts to our coverage of Part D 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 medical benefits. You can find out about your
coverage of these vaccines by going to Chapter 4, Medical Benefits Chart (what is
covered and what you pay).
o Other vaccines are considered Part D drugs. You can find these vaccines listed in
the plan’s List of Covered Drugs (Formulary).
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.

•

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

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(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 7 of this booklet (Asking us to
pay our share of a bill you have received for covered medical services
or drugs).
• You will be reimbursed the amount you paid less your normal [insert
as appropriate: coinsurance OR copayment] for the vaccine (including
administration) [Insert the following only if an out-of-network
differential is charged: less any difference between the amount the
doctor charges and what we normally pay. (If you 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 7 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.]

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Section 9.2

137

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 lose your prescription drug benefits 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.

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Your late enrollment penalty is considered 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 lose your prescription drug benefits.]]
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.

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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:
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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
What you pay for your Part D prescription drugs

140

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
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 6.
What you pay for your Part D prescription drugs

Section 11.2

141

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 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]

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).

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 6.
What you pay for your Part D prescription drugs

Section 11.4

142

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 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

143

Chapter 7. Asking us to pay our share of a bill you have received for
covered medical services or drugs
SECTION 1
Section 1.1

SECTION 2
Section 2.1
SECTION 3
Section 3.1
Section 3.2

SECTION 4
Section 4.1

Situations in which you should ask us to pay our share of
the cost of your covered services or drugs ................................. 144
If you pay our plan’s share of the cost of your covered services or drugs,
or if you receive a bill, you can ask us for payment .................................... 144
How to ask us to pay you back or to pay a bill you have
received ........................................................................................... 146
How and where to send us your request for payment ................................. 146
We will consider your request for payment and say yes or
no ..................................................................................................... 147
We check to see whether we should cover the service or drug and how
much we owe ............................................................................................... 147
If we tell you that we will not pay for all or part of the medical care or
drug, you can make an appeal ..................................................................... 148
Other situations in which you should save your receipts
and send copies to us .................................................................... 148
In some cases, you should send copies of your receipts to us to help us
track your out-of-pocket drug costs............................................................. 148

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

144

SECTION 1

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

Section 1.1

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

Sometimes when you get medical care or a prescription drug, you may need to pay the full cost
right away. Other times, you may find that you have paid more than you expected under the
coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back
is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve
paid more than your share of the cost for medical services or drugs that are covered by our plan.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received. In many cases, you should send this bill to us instead of paying it. We will
look at the bill and decide whether the services should be covered. If we decide they should be
covered, we will pay the provider directly.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay
a bill you have received:
1. When you’ve received medical care from a provider who is not in our plan’s
network
When you received care from a provider who is not part of our network, you are only
responsible for paying your share of the cost, not for the entire cost. (Your share of the cost
may be higher for an out-of-network provider than for a network provider.) You should ask
the provider to bill the plan for our share of the cost.
•

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

•

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

•

Please note: While you can get your care from an out-of-network provider, the
provider must be eligible to participate in Medicare. Except for emergency care, we
cannot pay a provider who is not eligible to participate in Medicare. If the provider is
not eligible to participate in Medicare, you will be responsible for the full cost of the
services you receive.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

145

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

You only have to pay your cost-sharing amount when you get services covered by our
plan. We do not allow providers to add additional separate charges, called “balance
billing.” This protection (that you never pay more than your cost-sharing amount)
applies even if we pay the provider less than the provider charges for a service and even
if there is a dispute and we don’t pay certain provider charges. For more information
about “balance billing,” go to Chapter 4, [edit section number as needed] Section 1.6.

•

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

•

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

3. 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
covered services or 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.)

4. 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 5,
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

146

5. 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 to look up your plan 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.

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

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

•

Save your receipt and send a copy to us when you ask us to pay you back. In some
situations, we may need to get more information from your doctor in order to pay you
back for our share of the cost.

[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 9 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 or to pay a bill you
have received

[Plans may edit this section to include a second address if they use different addresses for
processing medical and drug claims.]
Section 2.1

How and where to send us your request for payment

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

147

[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.)]

[Plans with different addresses for Part C and Part D claims may modify this paragraph as
needed and include the additional address] Mail your request for payment together with any
bills or 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 for medical care or 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, or you receive bills and you
don’t know what to do about those bills, we can help. You can also call if you want to give us
more information about a request for payment you have already sent to us.

SECTION 3

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

Section 3.1

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

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

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

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

•

148

If we decide that the medical care or drug is not covered, or you did not follow all the
rules, we will not pay for our share of the cost. Instead, we will send you a letter that
explains the reasons why we are not sending the payment you have requested 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 medical
care or 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.
For the details on how to make this appeal, go to Chapter 9 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is
a 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 9. Section 4 is an
introductory section that explains the process for coverage decisions and appeals and gives
definitions of terms such as “appeal.” Then after you have read Section 4, you can go to the
section in Chapter 9 that tells what to do for your situation:
•

If you want to make an appeal about getting paid back for a medical service, go to
Section 5.3 in Chapter 9.

•

If you want to make an appeal about getting paid back for a drug, go to Section 6.5 of
Chapter 9.

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.]

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 7.
Asking us to pay our share of a bill you have received for covered medical services
or drugs

149

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.

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 8.
Your rights and responsibilities

150

Chapter 8. Your rights and responsibilities
SECTION 1
Section 1.1

Section 1.9

Our plan must honor your rights as a member of the plan ........ 151
[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.) ............................ 151
We must treat you with fairness and respect at all times ............................ 151
We must ensure that you get timely access to your covered services and
drugs ............................................................................................................ 152
We must protect the privacy of your personal health information .............. 152
We must give you information about the plan, its network of providers,
and your covered services ........................................................................... 153
We must support your right to make decisions about your care ................. 155
You have the right to make complaints and to ask us to reconsider
decisions we have made .............................................................................. 156
What can you do if you believe you are being treated unfairly or your
rights are not being respected? .................................................................... 157
How to get more information about your rights .......................................... 157

SECTION 2
Section 2.1

You have some responsibilities as a member of the plan .......... 158
What are your responsibilities? ................................................................... 158

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 8.
Your rights and responsibilities

151

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 8.
Your rights and responsibilities

Section 1.3

152

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

[If your plan does not require any referrals or prior authorization within the preferred network,
delete the next three sentences and instead state: You have the right to choose a provider for
your care.] You have the right to choose a provider in the plan’s network. Call Member Services
to learn which doctors are accepting new patients (phone numbers are printed on the back cover
of this booklet). You also have the right to go to a women’s health specialist (such as a
gynecologist) without a referral and still pay the in-network cost-sharing amount.
As a plan member, you have the right to get appointments and covered services from your
providers within a reasonable amount of time. This includes the right to get timely services from
specialists when you need that care. You also have the right to get your prescriptions filled or
refilled at any of our network pharmacies without long delays.
[Regional PPOs: Explain how members will obtain care at in-plan rates in any areas of its
region where the plan has a limited contracted provider network.]
If you think that you are not getting your medical care or Part D drugs within a reasonable
amount of time, Chapter 9, Section 10 of this booklet tells what you can do. (If we have denied
coverage for your medical care or drugs and you don’t agree with our decision, Chapter 9,
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.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Your rights and responsibilities

•

153

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.

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 health care 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
providers, and your covered services

[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 health plans.

2015 Evidence of Coverage for [insert 2015 plan name]
Chapter 8.
Your rights and responsibilities

•

154

Information about our network providers including our network pharmacies.
o For example, you have the right to get information from us about the
qualifications of the providers and pharmacies in our network and how we pay the
providers in our network.
o [Plans that combine the provider and pharmacy directory may combine this bullet
and the one below and edit the information as needed] For a list of the providers
in the plan’s network, see the [insert name of provider directory].
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 providers or pharmacies, you can call
Member Services (phone numbers are printed on the back cover of this booklet)
or visit our website at [insert URL].

•

Information about your coverage and the rules you must follow when using your
coverage.
o In Chapters 3 and 4 of this booklet, we explain what medical services are covered
for you, any restrictions to your coverage, and what rules you must follow to get
your covered medical services.
o To get the details on your Part D prescription drug coverage, see Chapters 5 and 6
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 medical service or Part D drug is not covered for you, or if your coverage is
restricted in some way, you can ask us for a written explanation. You have the
right to this explanation even if you received the medical service or drug from an
out-of-network provider or pharmacy.
o If you are not happy or if you disagree with a decision we make about what
medical care or 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 9 of this booklet. It gives you the details about
how to make an appeal if you want us to change our decision. (Chapter 9 also tells
about how to make a complaint about quality of care, waiting times, and other
concerns.)
o If you want to ask our plan to pay our share of a bill you have received for
medical care or a Part D prescription drug, see Chapter 7 of this booklet.

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We must support your right to make decisions about your care

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

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

•

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

•

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

•

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

You have the right to give instructions about what is to be done if you are not
able to make medical decisions for yourself
[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.

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The legal documents that you can use to give your directions in advance in these situations are
called “advance directives.” There are different types of advance directives and different names
for them. Documents called “living will” and “power of attorney for health care” are examples
of advance directives.
If you want to use an “advance directive” to give your instructions, here is what to do:
•

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

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As explained in Chapter 9, what you need to do to follow up on a problem or concern depends on
the situation. You might need to ask our plan to make a coverage decision for you, make an
appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a
coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.
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.)

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

•

If you have any other health insurance coverage or 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 services from our
plan. This is called “coordination of benefits” because it involves coordinating
the health and drug benefits you get from our plan with any other health and 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 other health care providers that you are enrolled in our plan.
Show your plan membership card whenever you get your medical care or Part D
prescription drugs.

•

Help your doctors and other providers help you by giving them information, asking
questions, and following through on your care.
o To help your doctors and other health providers give you the best care, 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.

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

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

•

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

If you disagree with our decision to deny coverage for a service or drug,
you can make an appeal. Please see Chapter 9 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 [Plans offering Part D, insert: If you are required to pay a late enrollment penalty,
you must pay the penalty to keep your prescription drug coverage.]
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).
o If you move outside of our plan service area, you [if a continuation area is
offered, insert “generally” here and then explain the continuation area] cannot
remain a member of our plan. (Chapter 1 tells about our service area.) We can
help you figure out whether you are moving outside our service area. If you are
leaving our service area, 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.

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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.
•

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 9. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
BACKGROUND 164
SECTION 1
Section 1.1
Section 1.2

Introduction .................................................................................... 164
What to do if you have a problem or concern ............................................. 164
What about the legal terms? ........................................................................ 164

SECTION 2

You can get help from government organizations that are
not connected with us.................................................................... 165
Where to get more information and personalized assistance ...................... 165

Section 2.1
SECTION 3
Section 3.1

To deal with your problem, which process should you use? ..... 165
Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints? ................................... 165

COVERAGE DECISIONS AND APPEALS ................................................................ 166
SECTION 4
Section 4.1
Section 4.2
Section 4.3
SECTION 5
Section 5.1

Section 5.2
Section 5.3
Section 5.4
Section 5.5

A guide to the basics of coverage decisions and appeals ......... 166
Asking for coverage decisions and making appeals: the big picture .......... 166
How to get help when you are asking for a coverage decision or making
an appeal ...................................................................................................... 167
Which section of this chapter gives the details for your situation? ............. 168
Your medical care: How to ask for a coverage decision or
make an appeal ............................................................................... 169
This section tells what to do if you have problems getting coverage for
medical care or if you want us to pay you back for our share of the cost of
your care ...................................................................................................... 169
Step-by-step: How to ask for a coverage decision (how to ask our plan to
authorize or provide the medical care coverage you want) ......................... 170
Step-by-step: How to make a Level 1 Appeal (how to ask for a review of
a medical care coverage decision made by our plan) .................................. 174
Step-by-step: How a Level 2 Appeal is done .............................................. 177
What if you are asking us to pay you for our share of a bill you have
received for medical care? ........................................................................... 179

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SECTION 6
Section 6.1
Section 6.2
Section 6.3
Section 6.4
Section 6.5
Section 6.6
SECTION 7
Section 7.1
Section 7.2
Section 7.3
Section 7.4
SECTION 8

162

Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal ........................................................... 180
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 .............................. 180
What is an exception?.................................................................................. 182
Important things to know about asking for exceptions ............................... 184
Step-by-step: How to ask for a coverage decision, including an exception 184
Step-by-step: How to make a Level 1 Appeal (how to ask for a review of
a coverage decision made by our plan) ....................................................... 187
Step-by-step: How to make a Level 2 Appeal ............................................. 190
How to ask us to cover a longer inpatient hospital stay if
you think the doctor is discharging you too soon ...................... 192
During your inpatient hospital stay, you will get a written notice from
Medicare that tells about your rights ........................................................... 193
Step-by-step: How to make a Level 1 Appeal to change your hospital
discharge date .............................................................................................. 194
Step-by-step: How to make a Level 2 Appeal to change your hospital
discharge date .............................................................................................. 197
What if you miss the deadline for making your Level 1 Appeal? ............... 198

Section 8.5

How to ask us to keep covering certain medical services if
you think your coverage is ending too soon ............................... 201
This section is about three services only: Home health care, skilled
nursing facility care, and Comprehensive Outpatient Rehabilitation
Facility (CORF) services ............................................................................. 201
We will tell you in advance when your coverage will be ending................ 202
Step-by-step: How to make a Level 1 Appeal to have our plan cover your
care for a longer time................................................................................... 202
Step-by-step: How to make a Level 2 Appeal to have our plan cover your
care for a longer time................................................................................... 205
What if you miss the deadline for making your Level 1 Appeal? ............... 206

SECTION 9
Section 9.1
Section 9.2

Taking your appeal to Level 3 and beyond .................................. 209
Levels of Appeal 3, 4, and 5 for Medical Service Appeals ......................... 209
Levels of Appeal 3, 4, and 5 for Part D Drug Appeals ............................... 210

Section 8.1

Section 8.2
Section 8.3
Section 8.4

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MAKING COMPLAINTS ............................................................................................. 212
SECTION 10
Section 10.1
Section 10.2
Section 10.3
Section 10.4
Section 10.5

How to make a complaint about quality of care, waiting
times, customer service, or other concerns ................................ 212
What kinds of problems are handled by the complaint process? ................ 212
The formal name for “making a complaint” is “filing a grievance” ........... 214
Step-by-step: Making a complaint .............................................................. 214
You can also make complaints about quality of care to the Quality
Improvement Organization.......................................................................... 215
You can also tell Medicare about your complaint ....................................... 215

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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 “organization determination” or
“coverage determination,” and “Independent Review Organization” instead of “Independent
Review Entity.” It also uses abbreviations as little as possible.
However, it can be helpful – and sometimes quite important – for you to know the correct legal
terms for the situation you are in. Knowing which terms to use will help you communicate more
clearly and accurately when you are dealing with your problem and get the right help or
information for your situation. To help you know which terms to use, we include legal terms
when we give the details for handling specific types of situations.

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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 with 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 10 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 medical services and prescription drugs, including problems related to
payment. This is the process you use for issues such as whether something is covered or not
and the way in which something is covered.
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 medical services or drugs. For example, your plan network doctor makes a
(favorable) coverage decision for you whenever you receive medical care from him or her or if
your network doctor refers you to a medical specialist. You or your doctor can also contact us

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and ask for a coverage decision if your doctor is unsure whether we will cover a particular
medical service or refuses to provide medical care you think that you need. In other words, if you
want to know if we will cover a medical service before you receive it, you can ask us to make a
coverage decision for you.
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 service or 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 go on to a Level 2 Appeal. The Level
2 Appeal is conducted by an independent organization that is not connected to us. (In some
situations, your case will be automatically sent to the independent organization for a Level 2
Appeal. If this happens, we will let you know. In other situations, you will need to ask for a
Level 2 Appeal.) 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 can make a request for you.
o For medical care, your doctor can request a coverage decision or a Level 1 Appeal
on your behalf. If your appeal is denied at Level 1, it will be automatically
forwarded to Level 2. To request any appeal after Level 2, your doctor must be
appointed as your representative.

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o 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 provider, 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
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 4.3

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

There are four different types of situations that involve coverage decisions and appeals. Since
each situation has different rules and deadlines, we give the details for each one in a separate
section:
•

Section 5 of this chapter: “Your medical care: How to ask for a coverage decision or
make an appeal”

•

Section 6 of this chapter: “Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal”

•

Section 7 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you
think the doctor is discharging you too soon”

•

Section 8 of this chapter: “How to ask us to keep covering certain medical services if you
think your coverage is ending too soon” (Applies to these services only: home health care,
skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility
(CORF) services)

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

SECTION 5

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

Have you read Section 4 of this chapter (A guide to “the basics” of
coverage decisions and appeals)? If not, you may want to read it before
you start this section.
Section 5.1

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

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

NOTE: If the coverage that will be stopped is for hospital care, home health
care, skilled nursing facility care, or Comprehensive Outpatient
Rehabilitation Facility (CORF) services, you need to read a separate section of
this chapter because special rules apply to these types of care. Here’s what to read
in those situations:
o Chapter 9, Section 7: How to ask us to cover a longer inpatient hospital stay if
you think the doctor is discharging you too soon.

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o Chapter 9, Section 8: How to ask us to keep covering certain medical services if
you think your coverage is ending too soon. This section is about three services
only: home health care, skilled nursing facility care, and Comprehensive
Outpatient Rehabilitation Facility (CORF) services.
•

For all other situations that involve being told that medical care you have been getting
will be stopped, use this section (Section 5) as your guide for what to do.

Which of these situations are you in?
If you are in this situation:

This is what you can do:

Do you want to find out whether we will
cover the medical care or services you
want?

You can ask us to make a coverage decision for
you.
Go to the next section of this chapter, Section 5.2.

Have we already told you that we will not
cover or pay for a medical service 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 5.3 of this chapter.

Do you want to ask us to pay you back for
medical care or services you have already
received and paid for?

You can send us the bill.
Skip ahead to Section 5.5 of this chapter.

Section 5.2

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

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Step 1: You ask our plan to make a coverage decision on the medical care you
are requesting. If your health requires a quick response, you should ask us to make a
“fast coverage decision.”
Legal Terms
A “fast coverage decision” is called an
“expedited determination.”
How to request coverage for the medical care you want
•

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

•

For the details on how to contact us, 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 medical care.

Generally we use the standard deadlines for giving you our decision
When we give you our decision, we will use the “standard” deadlines unless we have agreed
to use the “fast” deadlines. A standard coverage decision means we will give you an
answer within 14 days after we receive your request.
•

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

•

If you believe we should not take extra days, you can file a “fast complaint” about
our decision to take extra days. When you file a fast complaint, we will give you
an answer to your complaint within 24 hours. (The process for making a complaint
is different from the process for coverage decisions and appeals. For more
information about the process for making complaints, including fast complaints,
see Section 10 of this chapter.)

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

A fast coverage decision means we will answer within 72 hours.
o However, we can take up to 14 more calendar days if we find that some
information that may benefit you is missing (such as medical records from
out-of-network providers), or if you need time to get information to us for the
review. If we decide to take extra days, we will tell you in writing.
o If you believe we should not take extra days, you can file a “fast complaint”
about our decision to take extra days. (For more information about the

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process for making complaints, including fast complaints, see Section 10 of
this chapter.) We will call you as soon as we make the decision.
•

To get a fast coverage decision, you must meet two requirements:
o You can get a fast coverage decision only if you are asking for coverage for
medical care you have not yet received. (You cannot get a fast coverage
decision if your request is about payment for medical care you have already
received.)
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 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 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 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 “fast complaint” about our decision
to give you a standard coverage decision instead of the fast coverage decision
you requested. (For more information about the process for making complaints,
including fast complaints, see Section 10 of this chapter.)

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

Generally, for a fast coverage decision, we will give you our answer within 72 hours.
o As explained above, we can take up to 14 more calendar days under certain
circumstances. If we decide to take extra days to make the coverage decision,
we will tell you in writing.
o If you believe we should not take extra days, you can file a “fast complaint”
about our decision to take extra days. When you file a fast complaint, we will
give you an answer to your complaint within 24 hours. (For more information
about the process for making complaints, including fast complaints, see Section
10 of this chapter.
o If we do not give you our answer within 72 hours (or if there is an extended
time period, by the end of that period), you have the right to appeal. Section 5.3
below tells how to make an appeal.

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•

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

•

If our answer is no to part or all of what you requested, we will send you a
detailed written explanation as to why we said no.

Deadlines for a “standard” coverage decision
•

Generally, for a standard coverage decision, we will give you our answer within 14
days of receiving your request.
o We can take up to 14 more calendar days (“an extended time period”) under
certain circumstances. If we decide to take extra days to make the coverage
decision, we will tell you in writing.
o If you believe we should not take extra days, you can file a “fast complaint”
about our decision to take extra days. When you file a fast complaint, we will
give you an answer to your complaint within 24 hours. (For more information
about the process for making complaints, including fast complaints, see Section
10 of this chapter.)
o If we do not give you our answer within 14 days (or if there is an extended time
period, by the end of that period), you have the right to appeal. Section 5.3
below tells how to make an appeal.

•

If our answer is yes to part or all of what you requested, we must authorize or
provide the coverage we have agreed to provide within 14 days after we received
your request. If we extended the time needed to make our coverage decision, we will
provide the coverage by the end of that extended period.

•

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

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

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

•

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

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Section 5.3

174

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

Step 1: You contact us and make your appeal. If your health requires a quick
response, you must ask for a “fast appeal.”
What to do
•

To start an appeal, you, your doctor, or your representative, must contact us.
For details on how to reach us for any purpose related to your appeal, go to
Chapter 2, Section 1 and look for section called, [plans may edit section title as
necessary] How to contact us when you are making an appeal about your medical
care.

•

If you are asking for a standard appeal, make your standard appeal in writing
by submitting a 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 us
when you are making an appeal about your medical care).]
o If you have someone appealing our decision for you other than your doctor,
your appeal must include an Appointment of Representative form authorizing
this person to represent you. (To get the form, call Member Services (phone
numbers are printed on the back cover of this booklet) and ask for the
“Appointment of Representative” form. It is also available on Medicare’s
website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf
[plans may also insert: or on our website at [insert website or link to form]].)
While we can accept an appeal request without the form, we cannot complete
our review until we receive it. If we do not receive the form within 44 days
after receiving your appeal request (our deadline for making a decision on
your appeal), your appeal request will be sent to the Independent Review
Organization for dismissal.

•

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

•

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

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

If your health requires it, ask for a “fast appeal” (you can make a request by calling us)
Legal Terms
A “fast appeal” is also called an
“expedited reconsideration.”
•

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

•

The requirements and procedures for getting a “fast appeal” are the same as those for
getting a “fast coverage decision.” To ask for a fast appeal, follow the instructions for
asking for a fast coverage decision. (These instructions are given earlier in this
section.)

•

If your doctor tells us that your health requires a “fast appeal,” we will give you a fast
appeal.

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

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

•

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

Deadlines for a “fast” appeal
•

When we are using the fast deadlines, we must give you our answer within 72 hours
after we receive your appeal. We will give you our answer sooner if your health
requires us to do so.

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o However, if you ask for more time, or if we need to gather more information
that may benefit you, we can take up to 14 more calendar days. If we decide
to take extra days to make the decision, we will tell you in writing.
o If we do not give you an answer within 72 hours (or by the end of the extended
time period if we took extra days), we are required to automatically send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent organization. Later in this section, we tell you about this
organization and explain what happens at Level 2 of the appeals process.
•

If our answer is yes to part or all of what you requested, we must authorize or
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
denial notice informing you that we have automatically sent your appeal to the
Independent Review Organization for a Level 2 Appeal.

Deadlines for a “standard” appeal
•

If we are using the standard deadlines, we must give you our answer within 30
calendar days after we receive your appeal if your appeal is about coverage for
services you have not yet received. We will give you our decision sooner if your
health condition requires us to.
o However, if you ask for more time, or if we need to gather more information
that may benefit you, we can take up to 14 more calendar days.
o If you believe we should not take extra days, you can file a “fast complaint”
about our decision to take extra days. When you file a fast complaint, we will
give you an answer to your complaint within 24 hours. (For more information
about the process for making complaints, including fast complaints, see Section
10 of this chapter.)
o If we do not give you an answer by the deadline above (or by the end of the
extended time period if we took extra days), we are required to send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent outside organization. Later in this section, we 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 authorize or
provide the coverage we have agreed to provide within 30 days after we receive
your appeal.

•

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Step 3: If our plan says no to part or all of your appeal, your case will
automatically be sent on to the next level of the appeals process.
•

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

Section 5.4

Step-by-step: How a Level 2 Appeal is done

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of
the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews
our decision for 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: The Independent Review Organization reviews your appeal.
•

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 handle
the job of being the Independent Review Organization. Medicare oversees its work.

•

We will send the information about your appeal to this organization. This information
is called your “case file.” You have the right to ask us for a copy of your case file.
[If a fee is charged, insert: We are allowed to charge you a fee for copying and
sending this information to you.]

•

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

•

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

If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2
•

If you had a fast appeal to our plan at Level 1, you will automatically receive a fast
appeal at Level 2. The review organization must give you an answer to your Level 2
Appeal within 72 hours of when it receives your appeal.

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However, if the Independent Review Organization needs to gather more information
that may benefit you, it can take up to 14 more calendar days.

If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level
2
•

If you had a standard appeal to our plan at Level 1, you will automatically receive a
standard appeal at Level 2. The review organization must give you an answer to your
Level 2 Appeal within 30 calendar days of when it receives your appeal.

•

However, if the Independent Review Organization needs to gather more information
that may benefit you, it can take up to 14 more calendar days.

Step 2: The Independent Review Organization gives you their answer.
The Independent Review Organization will tell you its decision in writing and explain the
reasons for it.
•

If the review organization says yes to part or all of what you requested, we must
authorize the medical care coverage within 72 hours or provide the service within 14
calendar days after we receive the decision from the review organization.

•

If this organization says no to part or all of your appeal, it means they agree with
us that your request (or part of your request) for coverage for medical care should not
be approved. (This is called “upholding the decision.” It is also called “turning down
your appeal.”)
o There is a certain dollar amount that must be in dispute to continue with the
appeals process. For example, to continue and make another appeal at Level 3,
the dollar value of the medical care coverage you are requesting must meet a
certain minimum. If the dollar value of the coverage you are requesting is too
low, you cannot make another appeal, which means that the decision at Level
2 is final. The written notice you get from the Independent Review
Organization will tell you how to find out the dollar amount to continue the
appeals process.

Step 3: If your case meets the requirements, you choose whether you want to
take your appeal further.
•

There are three additional levels in the appeals process after Level 2 (for a total of
five levels of appeal).

•

If your Level 2 Appeal is turned down and you meet the requirements to continue
with the appeals process, you must decide whether you want to go on to Level 3 and
make a third appeal. The details on how to do this are in the written notice you got
after your Level 2 Appeal.

•

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

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

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

If the medical care you paid for is covered and you followed all the rules, we will send
you the payment for our share of the cost of your medical care within 60 calendar days
after we receive your request. Or, if you haven’t paid for the services, we will send the
payment directly to the provider. When we send the payment, it’s the same as saying yes
to your request for a coverage decision.)

•

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

What if you ask for payment and we say that we will not pay?
If you do not agree with our decision to turn you down, you can make an appeal. If you make
an appeal, it means you are asking us to change the coverage decision we made when we turned
down your request for payment.
To make this appeal, follow the process for appeals that we describe in part 5.3 of this
section. Go to this part for step-by-step instructions. When you are following these instructions,
please note:
•

If you make an appeal for reimbursement, we must give you our answer within 60
calendar days after we receive your appeal. (If you are asking us to pay you back for
medical care you have already received and paid for yourself, you are not allowed to ask
for a fast appeal.)

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If the Independent Review Organization reverses our decision to deny payment, we must
send the payment you have requested to you or to the provider within 30 calendar days. If
the answer to your appeal is yes at any stage of the appeals process after Level 2, we must
send the payment you requested to you or to the provider within 60 calendar days.

SECTION 6

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 6.1

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 5, 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 5 (Using our plan’s
coverage for your Part D prescription drugs) and Chapter 6 (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.
Legal Terms
An initial coverage decision about your
Part D drugs is called a “coverage
determination.”

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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.
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 6.2 of this chapter.

Do you want us to cover a drug on our
You can ask us for a coverage decision.
Drug List and you believe you meet any Skip ahead to Section 6.4 of this chapter.
plan rules or restrictions (such as
getting approval in advance) for the
drug you need?
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 6.4 of this chapter.

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If you are in this situation:

This is what you can do:

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 6.5 of this chapter.

Section 6.2

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:
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 5 and look for Section 4).
Legal Terms
Asking for removal of a restriction on
coverage for a drug is sometimes called
asking for a “formulary exception.”

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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.

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].]

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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 6.5 tells how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.
Section 6.4

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 medical care or 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

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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 7 of
this booklet: Asking us to pay our share of a bill you have received for covered
medical services or drugs. Chapter 7 describes the situations in which you may
need to ask for reimbursement. It also tells how to send us the paperwork that asks
us to pay you back for our share of the cost of a drug you have paid for.

•

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 6.2 and 6.3 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.]

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.

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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 10 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.
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

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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.

•

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 6.5

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

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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).

•

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.

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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 6.4 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.
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 –

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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).

Section 6.6

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

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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.

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.

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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).

•

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

SECTION 7

How to ask us to cover a longer inpatient hospital
stay if you think the doctor is discharging you too
soon

When you are admitted to a hospital, you have the right to get all of your covered hospital
services that are necessary to diagnose and treat your illness or injury. For more information
about our coverage for your hospital care, including any limitations on this coverage, see Chapter
4 of this booklet: Medical Benefits Chart (what is covered and what you pay).
During your hospital stay, your doctor and the hospital staff will be working with you to prepare
for the day when you will leave the hospital. They will also help arrange for care you may need
after you leave.
•

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

•

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

•

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

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

During your hospital stay, you will be given a written notice called An Important Message from
Medicare about Your Rights. Everyone with Medicare gets a copy of this notice whenever they
are admitted to a hospital. Someone at the hospital (for example, a caseworker or nurse) must
give it to you within two days after you are admitted. If you do not get the notice, ask any
hospital employee for it. If you need help, please call Member Services (phone numbers are
printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
1. Read this notice carefully and ask questions if you don’t understand it. It tells you
about your rights as a hospital patient, including:
•

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

•

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

•

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

•

Your right to appeal your discharge decision if you think you are being discharged
from the hospital too soon.
Legal Terms
The written notice from Medicare tells you
how you can “request an immediate
review.” Requesting an immediate review
is a formal, legal way to ask for a delay in
your discharge date so that we will cover
your hospital care for a longer time.
(Section 7.2 below tells you how you can
request an immediate review.)

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

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

•

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

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

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

•

To look at a copy of this notice in advance, you can call Member Services (phone
numbers are printed on the back cover of this booklet) or 1-800 MEDICARE (1-800633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
You can also see it online at
http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp.

Section 7.2

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

If you want to ask for your inpatient hospital services to be covered by us for a longer time,
you will need to use the appeals process to make this request. Before you start, understand
what you need to do and what the deadlines are.
•

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

•

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

•

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

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal. It
checks to see if your planned discharge date is medically appropriate for you.
Step 1: Contact the Quality Improvement Organization in your state and ask for a
“fast review” of your hospital discharge. You must act quickly.
Legal Terms
A “fast review” is also called an
“immediate review.”
What is the Quality Improvement Organization?
•

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

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people with Medicare. This includes reviewing hospital discharge dates for people
with Medicare.
How can you contact this organization?
•

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

Act quickly:
•

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

•

If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to our plan instead. For details about
this other way to make your appeal, see Section 7.4.

Ask for a “fast review”:
•

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

Step 2: The Quality Improvement Organization conducts an independent review
of your case.
What happens during this review?
•

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

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•

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

•

By noon of the day after the reviewers informed our plan of your appeal, you
will also get a written notice that gives your planned discharge date and explains
in detail the reasons why your doctor, the hospital, and we think it is right
(medically appropriate) for you to be discharged on that date.
Legal Terms
This written explanation is called the “Detailed
Notice of Discharge.” You can get a sample of this
notice by calling Member Services (phone numbers
are printed on the back cover of this booklet) or 1800-MEDICARE (1-800-633-4227, 24 hours a day,
7 days a week. TTY users should call 1-877-4862048.) Or you can see a sample notice online at
http://www.cms.hhs.gov/BNI/

Step 3: Within one full day after it has all the needed information, the Quality
Improvement Organization will give you its answer to your appeal.
What happens if the answer is yes?
•

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

•

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

What happens if the answer is no?
•

If the review organization says no to your appeal, they are saying that your planned
discharge date is medically appropriate. If this happens, our coverage for your
inpatient hospital services will end at noon on the day after the Quality
Improvement Organization gives you its answer to your appeal.

•

If the review organization says no to your appeal and you decide to stay in the
hospital, then you may have to pay the full cost of hospital care you receive after
noon on the day after the Quality Improvement Organization gives you its answer to
your appeal.

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Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make
another appeal.
•

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

Section 7.3

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

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

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

Step 2: The Quality Improvement Organization does a second review of your
situation.
•

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

Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers
will decide on your appeal and tell you their decision.
If the review organization says yes:
•

We must reimburse you for our share of the costs of hospital care you have received
since noon on the day after the date your first appeal was turned down by the Quality
Improvement Organization. We must continue providing coverage for your
inpatient hospital care for as long as it is medically necessary.

•

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

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If the review organization says no:
•

It means they agree with the decision they made on your Level 1 Appeal and will not
change it.

•

The notice you get will tell you in writing what you can do if you wish to continue
with the review process. It will give you the details about how to go on to the next
level of appeal, which is handled by a judge.

Step 4: If the answer is no, you will need to decide whether you want to take your
appeal further by going on to Level 3.
•

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

•

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

Section 7.4

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

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

For details on how to contact us, 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 medical care.

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

Step 2: We do a “fast” review of your planned discharge date, checking to see if it
was medically appropriate.
•

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

•

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

Step 3: We give you our decision within 72 hours after you ask for a “fast review”
(“fast appeal”).
•

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

•

If we say no to your fast appeal, we are saying that your planned discharge date was
medically appropriate. Our coverage for your inpatient hospital services ends as of the
day we said coverage would end.
o If you stayed in the hospital after your planned discharge date, then you may
have to pay the full cost of hospital care you received after the planned discharge
date.

Step 4: If we say no to your fast appeal, your case will automatically be sent on to
the next level of the appeals process.
•

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

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

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

Step 2: The Independent Review Organization does a “fast review” of your
appeal. The reviewers give you an answer within 72 hours.
•

The Independent Review Organization is an independent organization that is hired
by Medicare. This organization is not connected with our plan and it is not a government
agency. This organization is a company chosen by Medicare to handle the job of being
the Independent Review Organization. Medicare oversees its work.

•

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

•

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

•

If this organization says no to your appeal, it means they agree with us that your
planned hospital discharge date was medically appropriate.
o The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It will
give you the details about how to go on to a Level 3 Appeal, which is handled by
a judge.

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Step 3: If the Independent Review Organization turns down your appeal, you
choose whether you want to take your appeal further.
•

There are three additional levels in the appeals process after Level 2 (for a total of
five levels of appeal). If reviewers say no to your Level 2 Appeal, you decide whether
to accept their decision or go on to Level 3 and make a third appeal.

•

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

SECTION 8

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

Section 8.1

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

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

Home health care services you are getting.

•

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

•

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

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

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We will tell you in advance when your coverage will be ending

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

The written notice tells you the date when we will stop covering the care for you.

•

The written notice also tells what you can do if you want to ask our plan to change
this decision about when to end your care, and keep covering it for a longer period of
time.
Legal Terms
In telling you what you can do, the written notice is telling
how you can request a “fast-track appeal.” Requesting a fasttrack appeal is a formal, legal way to request a change to our
coverage decision about when to stop your care. (Section 8.3
below tells how you can request a fast-track appeal.)
The written notice is called the “Notice of Medicare NonCoverage.” To get a sample copy, call Member Services
(phone numbers are printed on the back cover of this booklet)
or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. (TTY users should call 1-877-486-2048.) Or see
a copy online at http://www.cms.hhs.gov/BNI/

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

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

•

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

Section 8.3

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

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

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

•

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

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plan must follow. (If you think we are not meeting our deadlines, you can file a
complaint. Section 10 of this chapter tells you how to file a complaint.)
•

During a Level 1 Appeal, the Quality Improvement Organization reviews your appeal and
decides whether to change the decision made by our plan.
Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization
in your state and ask for a review. You must act quickly.
What is the Quality Improvement Organization?
•

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

How can you contact this organization?
•

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

What should you ask for?
•

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

Your deadline for contacting this organization.
•

You must contact the Quality Improvement Organization to start your appeal no later
than noon of the day after you receive the written notice telling you when we will stop
covering your care.

•

If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to us instead. For details about this
other way to make your appeal, see Section 8.5.

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Step 2: The Quality Improvement Organization conducts an independent review
of your case.
What happens during this review?
•

•

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

•

By the end of the day the reviewers informed us of your appeal, and you will
also get a written notice from us that explains in detail our reasons for ending
our coverage for your services.
Legal Terms
This notice explanation is called the
“Detailed Explanation of NonCoverage.”

Step 3: Within one full day after they have all the information they need, the
reviewers will tell you their decision.
What happens if the reviewers say yes to your appeal?
•

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

•

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

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

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

•

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

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Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make
another appeal.
•

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

•

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

Section 8.4

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

If the Quality Improvement Organization has turned down your appeal and you choose to
continue getting care after your coverage for the care has ended, then you can make a Level 2
Appeal. During a Level 2 Appeal, you ask the Quality Improvement Organization to take another
look at the decision they made on your first appeal. If the Quality Improvement Organization
turns down your Level 2 Appeal, you may have to pay the full cost for your home health care, or
skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF)
services after the date when we said your coverage would end.
Here are the steps for Level 2 of the appeal process:
Step 1: You contact the Quality Improvement Organization again and ask for
another review.
•

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

Step 2: The Quality Improvement Organization does a second review of your
situation.
•

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

Step 3: Within 14 days, the Quality Improvement Organization reviewers will
decide on your appeal and tell you their decision.
What happens if the review organization says yes to your appeal?
•

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

•

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

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What happens if the review organization says no?
•

It means they agree with the decision we made to your Level 1 Appeal and will not
change it.

•

Step 4: If the answer is no, you will need to decide whether you want to take your
appeal further.
•

There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If reviewers turn down your Level 2 Appeal, you can choose whether to
accept that decision or to go on to Level 3 and make another appeal. At Level 3, your
appeal is reviewed by a judge.

•

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

Section 8.5

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

You can appeal to us instead
As explained above in Section 8.3, you must act quickly to contact the Quality Improvement
Organization to start your first appeal (within a day or two, at the most). If you miss the deadline
for contacting this organization, there is another way to make your appeal. If you use this other
way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate Appeal
If you miss the deadline for contacting the Quality Improvement Organization, you can make an
appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines
instead of the standard deadlines.
Here are the steps for a Level 1 Alternate Appeal:
Legal Terms
A “fast” review (or “fast appeal”) is also
called an “expedited appeal”.
Step 1: Contact us and ask for a “fast review.”
•

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

Step 2: We do a “fast” review of the decision we made about when to end
coverage for your services.
•

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

•

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

Step 3: We give you our decision within 72 hours after you ask for a “fast review”
(“fast appeal”).
•

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

•

If we say no to your fast appeal, then your coverage will end on the date we told
you and we will not pay any share of the costs after this date.

•

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

Step 4: If we say no to your fast appeal, your case will automatically go on to the
next level of the appeals process.
•

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the decision we made when we said no to your “fast 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: We will automatically forward your case to the Independent Review
Organization.
•

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

Step 2: The Independent Review Organization does a “fast review” of your
appeal. The reviewers give you an answer within 72 hours.
•

The Independent Review Organization is an independent organization that is
hired by Medicare. This organization is not connected with our plan and it is not a
government agency. This organization is a company chosen by Medicare to handle
the job of being the Independent Review Organization. Medicare oversees its work.

•

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

•

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

•

If this organization says no to your appeal, it means they agree with the decision
our plan made to your first appeal and will not change it.
o The notice you get from the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It
will give you the details about how to go on to a Level 3 Appeal.

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Step 3: If the Independent Review Organization turns down your appeal, you
choose whether you want to take your appeal further.
•

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

•

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

SECTION 9

Taking your appeal to Level 3 and beyond

Section 9.1

Levels of Appeal 3, 4, and 5 for Medical Service 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 dollar value of the item or medical service you have appealed meets certain minimum
levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the
minimum level, you cannot appeal any further. If the dollar value is high enough, the written
response you receive to your Level 2 Appeal will explain who to contact and what to do to ask
for a Level 3 Appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
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 Administrative Law Judge says yes to your appeal, the appeals process may or
may not be over - We will decide whether to appeal this decision to Level 4. Unlike a
decision at Level 2 (Independent Review Organization), we have the right to appeal a
Level 3 decision that is favorable to you.
o If we decide not to appeal the decision, we must authorize or provide you with the
service within 60 calendar days after receiving the judge’s decision.
o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal
request with any accompanying documents. We may wait for the Level 4 Appeal
decision before authorizing or providing the service in dispute.

•

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.

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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.

If the answer is yes, or if the Appeals Council denies our request to review a
favorable Level 3 Appeal decision, the appeals process may or may not be over - We
will decide whether to appeal this decision to Level 5. Unlike a decision at Level 2
(Independent Review Organization), we have the right to appeal a Level 4 decision that is
favorable to you.
o If we decide not to appeal the decision, we must authorize or provide you with the
service within 60 calendar days after receiving the Appeals Council’s decision.
o If we decide to appeal the decision, we will let you know in writing.

•

If the answer is no or if the Appeals Council denies the review request, 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, 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 administrative appeals process.

Section 9.2

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.

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Level 3 Appeal

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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.

•

Level 4 Appeal

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

•

If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved. 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.

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MAKING COMPLAINTS
SECTION 10

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

If your problem is about decisions related to benefits, coverage, or
payment, then this section is not for you. Instead, you need to use the
process for coverage decisions and appeals. Go to Section 4 of this
chapter.
Section 10.1

What kinds of problems are handled by the complaint
process?

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

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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
(including care in the hospital)?

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

•

Are you having trouble getting an appointment, or waiting too long to
get it?
Have you been kept waiting too long by doctors, pharmacists, or
other health professionals? Or by our Member Services or other
staff at the plan?
o Examples include waiting too long on the phone, in the waiting
room, when getting a prescription, or in the exam room.

•

Cleanliness

•

Are you unhappy with the cleanliness or condition of a clinic,
hospital, or doctor’s office?

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 4-9 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 medical services or
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

Section 10.3

•

What this section calls a “complaint”
is also called a “grievance.”

•

Another term for “making a
complaint” is “filing a grievance.”

•

Another way to say “using the process
for complaints” is “using the process
for filing a grievance.”

Step-by-step: Making a complaint

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 10.4

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

You can make your complaint about the quality of care you received to 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 10.5

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
takes your complaints seriously and will use this information to help improve the quality of the
Medicare program.

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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 10. Ending your membership in the plan
SECTION 1
Section 1.1

Introduction .................................................................................... 218
This chapter focuses on ending your membership in our plan .................... 218

SECTION 2
Section 2.1
Section 2.2

When can you end your membership in our plan? ..................... 218
You can end your membership during the Annual Enrollment Period ....... 218
You can end your membership during the annual Medicare Advantage
Disenrollment Period, but your choices are more limited ........................... 220
In certain situations, you can end your membership during a Special
Enrollment Period........................................................................................ 220
Where can you get more information about when you can end your
membership? ............................................................................................... 222

Section 2.3
Section 2.4

SECTION 3
Section 3.1

How do you end your membership in our plan? ......................... 222
Usually, you end your membership by enrolling in another plan ............... 222

SECTION 4

Until your membership ends, you must keep getting your
medical services and drugs through our plan ............................. 223
Until your membership ends, you are still a member of our plan ............... 223

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 ............................................................... 224
When must we end your membership in the plan? ..................................... 224
We cannot ask you to leave our plan for any reason related to your health 225
You have the right to make a complaint if we end your membership in
our plan ........................................................................................................ 226

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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. [I-SNPs: Replace the text in this bullet with:
You can end your membership in the plan at any time. Section 2 tells you about
the types of plans you can enroll in.]
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 medical care and prescription drugs
through our plan until your membership ends.

SECTION 2

When can you end your membership in our plan?

[I-SNPs: Delete the following paragraph]
You may end your membership in our plan only during certain times of the year, known as
enrollment periods. All members have the opportunity to leave the plan during the Annual
Enrollment Period and during the annual Medicare Advantage Disenrollment Period. In certain
situations, you may also be eligible to leave the plan at other times of the year.
Section 2.1

You can end your membership during the Annual Enrollment
Period

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

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•

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 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 health plan. (You can choose a plan that covers prescription
drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan.
o – or – Original Medicare without a separate Medicare prescription drug plan.


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.

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 6, 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.

[I-SNPs: rename section 2.1 “You can end your membership at any time” and replace the
language in Section 2.1 with the following: You can end your membership in [insert 2015 plan
name] at any time.
•

When can you end your membership? You can end your membership in [insert 2015
plan name] at any time. Most people with Medicare can end their membership only
during certain times of the year. However, because you live in a nursing home or need a
level of care that is usually provided in a nursing home, you can end your membership at
any time.

•

What type of plan can you switch to? If you decide to change to a new plan, you can
choose any of the following types of plans:
o Another Medicare health plan. (You can choose a plan that covers prescription
drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan.
o – or – Original Medicare without a separate Medicare prescription drug plan.

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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 6, Section 10 for more information about the late
enrollment penalty.
•

When will your membership end? Your membership will usually end on the first day of
the month after your request to change your plan is received.]

Section 2.2

You can end your membership during the annual Medicare
Advantage Disenrollment Period, but your choices are more
limited

[I-SNPs: delete Section 2.2]
You have the opportunity to make one change to your health coverage during the annual
Medicare Advantage Disenrollment Period.
•

When is the annual Medicare Advantage Disenrollment Period? This happens every
year from January 1 to February 14.

•

What type of plan can you switch to during the annual Medicare Advantage
Disenrollment Period? During this time, you can cancel your Medicare Advantage Plan
enrollment and switch to Original Medicare. If you choose to switch to Original Medicare
during this period, you have until February 14 to join a separate Medicare prescription
drug plan to add drug coverage.

•

When will your membership end? Your membership will end on the first day of the
month after we get your request to switch to Original Medicare. If you also choose to
enroll in a Medicare prescription drug plan, your membership in the drug plan will begin
the first day of the month after the drug plan gets your enrollment request.

Section 2.3

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

[I-SNPs: delete Section 2.3]
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.

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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 Usually, when you have moved.
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
hospital.
o [Plans in states with PACE, insert: If you enroll in the Program of All-inclusive
Care for the Elderly (PACE).]

•

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 health plan. (You can choose a plan that covers prescription
drugs or one that does not cover prescription drugs.)
o Original Medicare with a separate Medicare prescription drug plan.
o – or – Original Medicare without a separate Medicare prescription drug plan.


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 6, Section 10 for more information about the late enrollment
penalty.
•

When will your membership end? Your membership will usually end on the first day of
the month after your request to change your plan is received.

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

[I-SNPs: renumber Section 2.4 as Section 2.2.]
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 [ISNPs: delete the rest of this sentence] during one of the enrollment periods (see Section 2 in this
chapter for information about the enrollment periods). However, 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. 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 6,
Section 10 for more information about the late enrollment penalty.

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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 health plan.

•

Enroll in the new Medicare health plan.
You will automatically be disenrolled from
[insert 2015 plan name] when your new
plan’s coverage begins.

•

Original Medicare with a separate
Medicare prescription drug 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.

•

Original Medicare without a separate
Medicare prescription drug plan.
o 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 6,
Section 10 for more information
about the late enrollment penalty.

•

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 1-800MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week, and ask to be disenrolled.
TTY users should call 1-877-486-2048.
You will be disenrolled from [insert 2015
plan name] when your coverage in Original
Medicare begins.

•

SECTION 4

Until your membership ends, you must keep getting
your medical services and 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 medical care and 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

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

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

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 and Part B.

•

If you move out of our service area.

•

If you are away from our service area for more than six months. [Plans with
visitor/traveler benefits should revise this bullet to indicate when members must be
disenrolled from the plan.]
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.)
o [Plans with visitor/traveler benefits, insert: Go to Chapter 4, Section 2.3 for
information on getting care when you are away from the service area through our
plan’s visitor/traveler benefit.]
o [Plans with grandfathered members who were outside of area prior to January
1999, insert: If you have been a member of our plan continuously since before
January 1999 and you were living outside of our service area before January
1999, you may continue your membership. However, if you move and your move
is to another location that is outside of our service area, you will be disenrolled
from our plan.]

•

[I-SNPs and C-SNPs insert: You do not meet the plan’s special eligibility requirements
as stated in Chapter 1, section 2.1]
o [I-SNPs and C-SNPs: Insert rules for members who no longer meet special
eligibility requirements.]

•

If you become incarcerated (go to prison).

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•

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 medical 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 medical care. (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).

Section 5.2

We cannot ask you to leave our plan for any reason related to
your health

[Chronic care SNPs should use the following title for this section instead: We cannot ask you to
leave our plan for any reason related to your health, unless you no longer have a medical
condition required for enrollment in [insert 2015 plan name].]

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[Insert 2015 plan name] is not allowed to ask you to leave our plan for any reason related to
your health.
[Chronic care SNPs replace sentence above with: In most cases, [insert 2015 plan name] cannot
ask you to leave our plan for any reason related to your health. The only time we are allowed to
do this is if you no longer have [insert as applicable: the medical condition OR both of the
medical conditions OR all of the medical conditions] required for enrollment in [insert 2015 plan
name]. (For information about the medical conditions required for enrollment, look in Chapter 1,
Section 2.1 of this booklet.)]
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 9, Section 10 for information about how to make
a complaint.

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Chapter 11. Legal notices
SECTION 1

Notice about governing law ........................................................... 228

SECTION 2

Notice about nondiscrimination .................................................... 228

SECTION 3

Notice about Medicare Secondary Payer subrogation rights ..... 228

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[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.]

SECTION 1

Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply
because they are required by law. This may affect your rights and responsibilities even if the
laws are not included or explained in this document. The principal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under the Social
Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other
Federal laws may apply and, under certain circumstances, the laws of the state you live in.

SECTION 2

Notice about nondiscrimination

We don’t discriminate based on a person’s race, disability, religion, sex, health, ethnicity, creed,
age, or national origin. All organizations that provide Medicare Advantage Plans, like our plan,
must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with
Disabilities Act, all other laws that apply to organizations that get Federal funding, and any other
laws and rules that apply for any other reason.

SECTION 3

Notice about Medicare Secondary Payer subrogation
rights

We have the right and responsibility to collect for covered Medicare services 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 Advantage Organization, 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 12. Definitions of important words
[Plans should insert definitions as appropriate to the plan type described in the EOC. You may
insert definitions not included in this model and exclude model definitions not applicable to your
plan, or to your contractual obligations with CMS or enrolled Medicare beneficiaries.]
[If 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.]
[If you use any of the following terms in your EOC, you must add a definition of the term to the
first section where you use it and here in Chapter 12 with a reference from the section where you
use it: IPA, network, PHO, plan medical group, Point of Service.]
Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates
exclusively for the purpose of furnishing outpatient surgical services to patients not requiring
hospitalization and whose expected stay in the center does not exceed 24 hours.
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.
Appeal – An appeal is something you do if you disagree with our decision to deny a request for
coverage of health care services or prescription drugs or payment for services or drugs you
already received. You may also make an appeal if you disagree with our decision to stop services
that you are receiving. For example, you may ask for an appeal if we don’t pay for a drug, item,
or service you think you should be able to receive. [Insert as applicable: Chapter 7 OR Chapter
9] explains appeals, including the process involved in making an appeal.
Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the
plan’s allowed cost-sharing amount. As a member of [insert 2015 plan name], you only have to
pay our plan’s cost-sharing amounts when you get services covered by our plan. We do not allow
providers to “balance bill” or otherwise charge you more than the amount of cost-sharing your
plan says you must pay.
Benefit Period – [Modify definition as needed if plan uses benefit periods for SNF stays but not
for inpatient hospital stays.] The way that [insert if applicable: both our plan and] Original
Medicare measures your use of hospital and skilled nursing facility (SNF) services. [Plans that
offer a more generous benefit period, revise the following sentences to reflect the plan’s benefit
period.] A benefit period begins the day you go into a hospital or skilled nursing facility. The
benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a
SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit
period has ended, a new benefit period begins. [Insert if applicable: You must pay the inpatient
hospital deductible for each benefit period.] There is no limit to the number of benefit periods.

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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 services or
prescription drugs [insert if applicable: after you pay any deductibles]. Coinsurance is usually a
percentage (for example, 20%).
Combined Maximum Out-of-Pocket Amount – This is the most you will pay in a year for all
[insert if applicable: Part A and Part B] services from both network (preferred) providers and
out-of-network (non-preferred) providers. [Plans with service category MOOPs insert: In
addition to the maximum out-of-pocket amount for covered [insert if applicable: Part A and Part
B] medical services, we also have a maximum out-of-pocket amount for certain types of
services.] See Chapter 4, Section 1, [insert subsection number] for information about your
combined maximum out-of-pocket amount.
Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides
rehabilitation services after an illness or injury, and provides a variety of services including
physical therapy, social or psychological services, respiratory therapy, occupational therapy and
speech-language pathology services, and home environment evaluation services.
Copayment – An amount you may be required to pay as your share of the cost for a medical
service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A
copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or
$20 for a doctor’s visit or prescription drug.
Cost-sharing – Cost-sharing refers to amounts that a member has to pay when services or 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 services or drugs are covered; (2) any fixed
“copayment” amount that a plan requires when a specific service or drug is received; or (3) any
“coinsurance” amount, a percentage of the total amount paid for a service or drug, that a plan
requires when a specific service drug is 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.

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[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 9 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.
Covered Services – The general term we use in this EOC to mean all of the health care services
and supplies that are covered by our plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll
in Medicare prescription drug coverage later.
Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or other
facility setting when you do not need skilled medical care or skilled nursing care. Custodial care
is personal care that can be provided by people who don’t have professional skills or training,
such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed
or chair, moving around, and using the bathroom. It may also include the kind of health-related
care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial
care.
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 health care or 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.

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Durable Medical Equipment – Certain medical equipment that is ordered by your doctor for
medical reasons. Examples are walkers, wheelchairs, or hospital beds.
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.
Emergency Care – Covered services that are: 1) rendered by a provider qualified to furnish
emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical
condition.
Evidence of Coverage (EOC) and Disclosure Information – This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Exception – A type of coverage determination that, if approved, allows you to get a drug that is
not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at
preferred 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 providers or
pharmacies, including a complaint concerning the quality of your care. This type of complaint
does not involve coverage or payment disputes.
Home Health Aide – A home health aide provides services that don’t need the skills of a
licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet,
dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing
license or provide therapy.
Hospice - An enrollee who has 6 months or less to live has the right to elect hospice. We, your
plan, must provide you with a list of hospices in your geographic area. If you elect hospice and
continue to pay premiums you are still a member of our plan. You can still obtain all medically
necessary services as well as the supplemental benefits we offer. The hospice will provide
special treatment for your state.

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Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital
for skilled medical services. Even if you stay in the hospital overnight, you might still be
considered an “outpatient.”
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 percent 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-ofpocket 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.
In-Network Maximum Out-of-Pocket Amount – The most you will pay for covered [insert if
applicable: Part A and Part B] services received from network (preferred) providers. After you
have reached this limit, you will not have to pay anything when you get covered services from
network providers for the rest of the contract year. However, until you reach your combined outof-pocket amount, you must continue to pay your share of the costs when you seek care from an
out-of-network (non-preferred) provider. [Plans with service category MOOPs insert: In
addition to the maximum out-of-pocket amount for covered [insert if applicable: Part A and Part
B] medical services, we also have a maximum out-of-pocket amount for certain types of
services.] See Chapter 4, Section 1, [insert subsection number] for information about your innetwork maximum out-of-pocket amount.
Institutional Special Needs Plan (SNP) – A Special Needs Plan that enrolls eligible individuals
who continuously reside or are expected to continuously reside for 90 days or longer in a longterm care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF);
nursing facility (NF); (SNF/NF); an intermediate care facility for the mentally retarded
(ICF/MR); and/or an inpatient psychiatric facility. An institutional Special Needs Plan to serve
Medicare residents of LTC facilities must have a contractual arrangement with (or own and
operate) the specific LTC facility(ies).
Institutional Equivalent Special Needs Plan (SNP) – An institutional Special Needs Plan that
enrolls eligible individuals living in the community but requiring an institutional level of care

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based on the State assessment. The assessment must be performed using the same respective
State level of care assessment tool and administered by an entity other than the organization
offering the plan. This type of Special Needs Plan may restrict enrollment to individuals that
reside in a contracted assisted living facility (ALF) if necessary to ensure uniform delivery of
specialized care.
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
prescription drug plan costs, you will 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 5, Section 3 for more
information about a medically accepted indication.
Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of medical practice.
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 Disenrollment Period – A set time each year when members in a
Medicare Advantage plan can cancel their plan enrollment and switch to Original Medicare. The
Medicare Advantage Disenrollment Period is from January 1 until February 14, 2015.
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. When you are enrolled in a

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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.
Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare
health plans, including our plan, must cover all of the services that are covered by Medicare Part
A and 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

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our plan. In most cases, your prescriptions are covered only if they are filled at one of our
network pharmacies.
Network Provider – “Provider” is the general term we use for doctors, other health care
professionals, hospitals, and other health care facilities that are licensed or certified by Medicare
and by the State to provide health care services. We call them “network providers” when they
[insert if appropriate: have an agreement with our plan to] accept our payment as payment in
full, and in some cases to coordinate as well as provide covered services to members of our plan.
Our plan pays network providers based on the agreements it has with the providers or if the
providers agree to provide you with plan-covered services. Network providers may also be
referred to as “plan providers.”
[Include if applicable: Optional Supplemental Benefits – Non-Medicare-covered benefits that
can be purchased for an additional premium and are not included in your package of benefits. If
you choose to have optional supplemental benefits, you may have to pay an additional premium.
You must voluntarily elect Optional Supplemental Benefits in order to get them.]
Organization Determination – The Medicare Advantage plan has made an organization
determination when it makes a decision about whether items or services are covered or how
much you have to pay for covered items or services. The Medicare Advantage plan’s network
provider or facility has also made an organization determination when it provides you with an
item or service, or refers you to an out-of-network provider for an item or service. Organization
determinations are called “coverage decisions” in this booklet. Chapter 9 explains how to ask us
for a coverage decision.
Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare
is offered by the government, and not a private health plan such as 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-Network Provider or Out-of-Network Facility – A provider or facility with which we
have not arranged to coordinate or provide covered services to members of our plan. Out-ofnetwork providers are providers that are not employed, owned, or operated by our plan or are not
under contract to deliver covered services to you. Using out-of-network providers or facilities is
explained in this booklet in Chapter 3.

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Out-of-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharing
requirement to pay for a portion of services or drugs received is also referred to as the member’s
“out-of-pocket” cost requirement.
[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 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 high-quality care
they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits
through the plan.]
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.
Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a
Medicare Advantage Plan that has a network of contracted providers that have agreed to treat
plan members for a specified payment amount. A PPO plan must cover all plan benefits whether
they are received from network or out-of-network providers. Member cost-sharing will generally
be higher when plan benefits are received from out-of-network providers. PPO plans have an
annual limit on your out-of-pocket costs for services received from network (preferred) providers
and a higher limit on your total combined out-of-pocket costs for services from both in-network
(preferred) and out-of-network (non-preferred) providers.
Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
[Plans that do not use PCPs, omit] Primary Care [insert as appropriate: Physician OR
Provider] (PCP) – Your primary care provider is the doctor or other provider you see first for
most health problems. He or she makes sure you get the care you need to keep you healthy. He
or she also may talk with other doctors and health care providers about your care and refer you to
them. In many Medicare health plans, you must see your primary care provider before you see
any other health care provider. See Chapter 3, Section 2.1 for information about Primary Care
[insert as appropriate: Physicians OR Providers].

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Prior Authorization – Approval in advance to get services or certain drugs that may or may not
be on our formulary. [Edit or delete as necessary to make the definition applicable to your
plan.]In the network portion of a PPO, some in-network medical services are covered only if
your doctor or other network provider gets “prior authorization” from our plan. In a PPO, you do
not need prior authorization to obtain out-of-network services. However, you may want to check
with the plan before obtaining services from out-of-network providers to confirm that the service
is covered by your plan and what your cost-sharing responsibility is. Covered services that need
prior authorization are marked in the Benefits Chart in Chapter 4. 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.
Rehabilitation Services – These services include physical therapy, speech and language
therapy, and occupational therapy.
Service Area – A geographic area where a health plan accepts members if it limits membership
based on where people live. For plans that limit which doctors and hospitals you may use, it’s
also generally the area where you can get routine (non-emergency) services. The plan may
disenroll you if you permanently move out of the plan’s service area.
Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided
on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing facility care
include physical therapy or intravenous injections that can only be given by a registered nurse or
doctor.
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.
Special Needs Plan – A special type of Medicare Advantage Plan that provides more focused
health care for specific groups of people, such as those who have both Medicare and Medicaid,
who reside in a nursing home, or who have certain chronic medical conditions.
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

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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.
Urgently Needed Care – Urgently needed care is care provided to treat a non-emergency,
unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently
needed care may be furnished by network providers or by out-of-network providers when
network providers are temporarily unavailable or inaccessible.

[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 Preferred Provider Organization Medicare Advantage (PPO MA)Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Te
Subject	Proposed revisions for 2015 Preferred Provider Organization (PPO MA) Annual Notice of Change (ANOC) and Evidence of Coverage (EO
Author	Centers for Medicare & Medicaid Services
File Modified	2014-01-23
File Created	2014-01-23