Form CMS-R-246 Prescription Drug Plan Survey

MA & PDP CAHPS Survey
Prescription Drug Plan Survey
INITIAL COVER LETTER - English
[SURVEY VENDOR LOGO]
[SURVEY VENDOR ADDRESS]

[PLAN LOGO ONLY NO ADDRESS]

Dear Medicare Beneficiary:
As a person with Medicare, you deserve to get the highest quality medical care when you need it. The
Centers for Medicare & Medicaid Services (CMS) is the federal agency that administers the Medicare
program and its responsibility is to ensure that you get high quality care at a reasonable price. One of
the ways CMS can fulfill that responsibility is to find out directly from you about the care you are
currently receiving under the Medicare program.
CMS is conducting a survey of people with Medicare who are enrolled in a Medicare prescription drug
plan to learn more about the services you receive through your plan. Your name was selected at
random by CMS from among the enrollees in your plan. We would greatly appreciate it if you would
take the time, about 15 minutes, to fill out this questionnaire. The accuracy of the results depends on
getting answers from you and other people with Medicare selected for this survey. This is your
opportunity to help CMS and your prescription drug plan serve you better.
If you changed your Medicare prescription drug plan for 2015, please answer the questions in the
survey thinking about your experiences in the last six months of 2014. All information you provide will
be held in confidence and is protected by the Privacy Act. The information you provide will not be
shared with anyone other than authorized persons at CMS and [SURVEY VENDOR NAME]. You do
not have to participate in this survey. Your help is voluntary, and your decision to participate or
not to participate will not affect your Medicare benefits in any way. However, your knowledge and
experiences will help other people with Medicare make more informed choices.
If you have any questions about the survey, please don’t hesitate to call [VENDOR DESIGNATE] with
[SURVEY VENDOR NAME] toll-free at 1-XXX-XXX-XXXX, Monday through Friday, between xx:xx a.m.
and xx:xx p.m.
Thank you in advance for your participation.
Sincerely,
Signature
[SENIOR OFFICIAL OF SURVEY VENDOR]
Nota: Si le gustaría recibir una copia de la encuesta en español, por favor llame gratis a [VENDOR
DESIGNATE] de [SURVEY VENDOR NAME] al 1-xxx- xxx-xxxx de lunes a viernes entre XX:XX a.m. y
XX:XX p.m.

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“Medicare Satisfaction Survey”
Prescription Drug Plan Survey
MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months. Answer
each question thinking about yourself. Please take the time to complete this survey. Your
answers are very important to us. Please return the survey with your answers in the enclosed
postage-paid envelope to [Survey Vendor].


Answer all the questions by putting an “X” in the box to the left of your answer, like this:
Yes



Be sure to read all the answer choices given before marking your answer.
 You are sometimes told not to answer some questions in this survey. When this happens
you will see an arrow with a note that tells you what question to answer next, like this: [If
No, Go to Question 3]. See the example below:

EXAMPLE
1. Do you wear a hearing aid now?
Yes 0
No If No, Go to Question 3
2. How long have you been wearing a hearing aid?
Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid
3. In the last 6 months, did you have any headaches?
Yes
No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0732. The
time required to complete this information collection is estimated to average 15 minutes, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If
you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.

1.

Our records show that in 2014 your
prescriptions were covered by the
Medicare prescription drug plan
named on the back page.
Is that right?

4.

Yes If Yes, Go to Question 3
No
2.

Never
Sometimes
Usually
Always
I did not try to get information
or help from my prescription
drug plan’s customer service in
the last 6 months  Go to
Question 6

Please write below the name of
the Medicare prescription drug
plan you had in 2014 and complete
the rest of the survey based on the
experiences you had with that
plan. (Please print)
___________________________
5.

3.

In the last 6 months, how often did
your prescription drug plan’s
customer service give you the
information or help you needed
about prescription drugs?

You contact customer service to
get information about what is
covered and how to use a drug
plan. In the last 6 months, did you
try to get information or help
about prescription drugs from your
prescription drug plan’s customer
service?

In the last 6 months, how often did
your prescription drug plan’s
customer service staff treat you
with courtesy and respect when
you tried to get information or
help about prescription drugs?
Never
Sometimes
Usually
Always
I did not try to get information
or help from my prescription
drug plan’s customer service in
the last 6 months

Yes
No If No, Go to Question 6

6.

In the last 6 months, did you try to
get information from your
prescription drug plan about which
prescription medicines were
covered?
Yes
No If No, Go to Question 8

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7.

In the last 6 months, how often did
your prescription drug plan’s
customer service give you all the
information you needed about
which prescription medicines were
covered?
Never
Sometimes
Usually
Always
I did not try to get information
or help from my prescription
drug plan’s customer service in
the last 6 months

8.

In the last 6 months, did you try to
get information from your
prescription drug plan about how
much you would have to pay for
your prescription medicines?
Yes
No If No, Go to Question 10

9.

In the last 6 months, how often did
your prescription drug plan’s
customer service give you all the
information you needed about
how much you would have to pay
for your prescription medicines?
Never
Sometimes
Usually
Always
I did not try to get information
or help from my prescription
drug plan’s customer service in
the last 6 months

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10. In the last 6 months, how many
different prescription medicines
did you fill or have refilled?
None
1 to 2 medicines
3 to 5 medicines
6 or more medicines
11. In the last 6 months, did a doctor
prescribe a medicine for you that
your prescription drug plan did not
cover?
Yes
No If No, Go to Question 17
12. When this happened, did you
contact your prescription drug
plan to ask them to cover the
medicine your doctor prescribed?
Yes
No If No, Go to Question 17
All my prescribed medicines
are covered Go to Question
17

13. When you contacted your
prescription drug plan about the
decision not to cover a
prescription medicine did they…
Please mark one or more.
Tell you that you can file an
appeal
Offer to send you forms that
you need in order to file an
appeal
Suggest how to resolve your
complaint
Listen to your complaint but
did not help to resolve it
Discourage you from taking
action
Do none of the above
All my prescribed medicines
were covered
14. Thinking about the complaint
process, regardless of whether you
agree or disagree with the final
outcome, how satisfied are you
with how your plan handled your
complaint?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor
satisfied
Somewhat satisfied
Very satisfied

15. How long did it take for your plan
to settle your complaint?
Same day
1 week
2 weeks
3 weeks
4 or more weeks
I am still waiting for it to be
settled
16. Was your complaint or problem
settled to your satisfaction?
Yes
No
I am still waiting for it to be
settled
17. In the last 6 months, did anyone
from a doctor’s office, pharmacy
or your prescription drug plan
contact you:
Yes

No

a. To make sure you
filled or refilled a
prescription?
b. To make sure you
were taking
medications as
directed?

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18. In the last 6 months, how often
was it easy to use your
prescription drug plan to get the
medicines your doctor prescribed?
Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to get any medicines
in the last 6 months
19. In the last 6 months, did you ever
use your prescription drug plan to
fill a prescription at your local
pharmacy?
Yes
No If No, Go to Question 21
20. In the last 6 months, how often
was it easy to use your
prescription drug plan to fill a
prescription at your local
pharmacy?
Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to fill a prescription
at my local pharmacy in the
last 6 months

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21. In the last 6 months, did you ever
use your prescription drug plan to
fill a prescription by mail?
Yes
No If No, Go to Question 23
I am not sure if my drug plan
offers prescriptions by mail
Go to Question 23
22. In the last 6 months, how often
was it easy to use your
prescription drug plan to fill a
prescription by mail?
Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to fill a prescription
by mail in the last 6 months
I am not sure if my drug plan
offers prescriptions by mail

23. Using any number from 0 to 10,
where 0 is the worst prescription
drug plan possible and 10 is the
best prescription drug plan
possible, what number would you
use to rate your prescription drug
plan?
0 - Worst prescription drug
plan possible
1
2
3
4
5
6
7
8
9
10 - Best prescription drug plan
possible
24. Would you recommend your
prescription drug plan for
coverage of prescription drugs to
other people like yourself?
Definitely yes
Somewhat yes
Somewhat no
Definitely no

About You
25. In general, how would you rate
your overall health?
Excellent
Very good
Good
Fair
Poor
26. In general, how would you rate
your overall mental or emotional
health?
Excellent
Very good
Good
Fair
Poor
27. In the past 12 months, have you
seen a doctor or other health
provider 3 or more times for the
same condition or problem?
Yes
No If No, Go to Question 29
28. Is this a condition or problem that
has lasted for at least 3 months?
Yes
No
29. Do you now need or take any
medicine prescribed by a doctor
for any condition?
Yes
No If No, Go to Question 31

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30. Is this to treat a condition that has
lasted for at least 3 months?

Yes
No
Don’t know

Yes
No No
31. In the last 6 months, did you delay
or not fill a prescription because
you felt you could not afford it?
Yes
No
My doctor did not prescribe
any medicines for me in the
last 6 months

Yes
No
Don’t know

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35. Have you ever had a pneumonia
shot? This shot is usually given
only once or twice in a person’s
lifetime and is different from a flu
shot. It is also called the
pneumococcal vaccine.
Yes
No
Don’t know

32. In the last 6 months, did you
receive any mail order medicines
that you did not request?

33. Has a doctor ever told you that
you had any of the following
conditions?
Yes
a. A heart attack?
b. Angina or coronary
heart disease?
c. Hypertension
or high blood
pressure?
d. Cancer, other than
skin cancer?
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary disease)?
f. Any kind of diabetes
or high blood
sugar?

34. Have you had a flu shot since July
1, 2014?

36. Do you now smoke cigarettes or
use tobacco every day, some days,
or not at all?

No

Every day
Some days
Not at all If Not at all, Go to
Question 38
Don’t know If Don’t know,
Go to Question
38

37. In the last 6 months, how often
were you advised to quit smoking
or using tobacco by a doctor or
other health provider?

40. What is your race? Please mark
one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska Native

Never
Sometimes
Usually
Always
I had no visits in the last 6
months

38. What is the highest grade or level
of school that you have
completed?
8th grade or less
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree

39. Are you of Hispanic or Latino origin
or descent?

41. How many people live in your
household now, including
yourself?
1 person
2 to 3 people
4 or more people

42.

The Medicare Program is trying to
learn more about the health care
or services provided to people with
Medicare. May Medicare contact
you again about the health care
services that you received?
Yes
No

Yes, Hispanic or Latino
No, not Hispanic or Latino

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43. Did someone help you complete
this survey?

44. How did that person help you?
Please mark one or more.

Yes
No  Thank you. Please
return the completed
survey in the postagepaid envelope.

Read the questions to me
Wrote down the answers I
gave
Answered the questions for me
Translated the questions into
my language
Helped in some other way

Thank you.
Please return the completed survey in the postage-paid envelope.

[SURVEY VENDOR ADDRESS]

Contract Name: ____________________

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