Crosswalk - Prescription Drug Plan Survey

Survey Item Crosswalk for PDP Questionnaires
Survey Section
Medicare
Prescription Drug
Plan Experiences

Proposed Question

Existing Question

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?
2. 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)
3. In the last 6 months, did you try to get
information or help about prescription drugs from
your prescription drug plan’s customer service?

1. Our records show that in 2011 your
prescriptions were covered by the Medicare
prescription drug plan named on the back page.
Is that right?
2. Please write below the name of the Medicare
prescription drug plan you had in 2011 and
complete the rest of the survey based on the
experiences you had with that plan. (Please print)
3. In the last 6 months, did you try to get
information or help about prescription drugs from
your prescription drug plan’s customer service?
4. 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?
5. 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?
6. In the last 6 months, did you try to get
information from your prescription drug plan
about which prescription medicines were
covered?
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?
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?
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
medicine?
10. In the last 6 months, how many different
prescription medicines did you fill or have
refilled?
11. In the last 6 months, did a doctor prescribe a
medicine for you that your prescription drug plan
did not cover?
12. When this happened, did you contact your
prescription drug plan to ask them to cover the
medicine your doctor prescribed?

4. 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?
5. 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?
6. In the last 6 months, did you try to get
information from your prescription drug plan
about which prescription medicines were
covered?
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?
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?
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
medicine?
10. In the last 6 months, how many different
prescription medicines did you fill or have
refilled?
11. In the last 6 months, did a doctor prescribe a
medicine for you that your prescription drug plan
did not cover?
12. When this happened, did you contact your
prescription drug plan to ask them to cover the
medicine your doctor prescribed?

Survey Section

Proposed Question

Existing Question

13. When you contacted your prescription drug
plan about the decision not to cover a
prescription medicine did they…

13. When you contacted your prescription drug
plan about the decision not to cover a
prescription medicine did they…

13a. Tell you that you can file an appeal
13b. Offer to send you forms that you need in
order to file an appeal
13c. Suggest how to resolve your complaint
13d. Listen to your complaint but did not help to
resolve it
13e. Discourage you from taking action
13f. Do none of the above
13g. All my prescribed medicines were covered

13a. Tell you that you can file an appeal
13b. Offer to send you forms that you need in
order to file an appeal
13c. Suggest how to resolve your complaint
13d. Listen to your complaint but did not help to
resolve it
13e. Discourage you from taking action
13f. Do none of the above
13g. 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?
15. How long did it take for your plan to settle
your complaint?
16. Was your complaint or problem settled to
your satisfaction?
17. In the last 6 months, did anyone from a
doctor’s office, pharmacy or your prescription
drug plan contact you:

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?
15. How long did it take for your plan to settle
your complaint?
16. Was your complaint or problem settled to
your satisfaction?

17a. To make sure you filled or refilled a
prescription?
17b. To make sure you were taking medications
as directed?
18. In the last 6 months, how often was it easy to
use your prescription drug plan to get the
medicines your doctor prescribed?

No comparable question

17. In the last 6 months, how often was it easy to
use your prescription drug plan to get the
medicines your doctor prescribed?

19. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription at your
local pharmacy?

18. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription at your
local pharmacy?

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?

19. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription at your local pharmacy?

21. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription by
mail?
22. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription by mail?

20. In the last 6 months, did you ever use your
prescription drug plan to fill a prescription 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?

21. In the last 6 months, how often was it easy to
use your prescription drug plan to fill a
prescription by mail?
22. 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?

Survey Section

About You

Proposed Question

Existing Question

24. Would you recommend your prescription drug
plan for coverage of prescription drugs to other
people like yourself?
25. In general, how would you rate your overall
health?
26. In general, how would you rate your overall
mental or emotional health?
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?
28. Is this a condition or problem that has lasted
for at least 3 months?
29. Do you now need or take any medicine
prescribed by a doctor for any condition?
30. Is this to treat a condition that has lasted for
at least 3 months?
31. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford
it?
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?

23. Would you recommend your prescription drug
plan for coverage of prescription drugs to other
people like yourself?
24. In general, how would you rate your overall
health?
25. In general, how would you rate your overall
mental health?
26. In the past 12 months, have you seen a doctor
or other health provider 3 or more times for the
same condition or problem?
27. Is this a condition or problem that has lasted
for at least 3 months?
28. Do you now need or take medicine prescribed
by a doctor?
29. Is this to treat a condition that has lasted for
at least 3 months?
30. In the last 6 months, did you delay or not fill a
prescription because you felt you could not afford
it?

33a. A heart attack?
33b. Angina or coronary heart disease?
NO SUCH RESPONSE OPTION
33c. Hypertension or high blood pressure?
33d. Cancer, other than skin cancer?
33e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
33f. Any kind of diabetes or high blood sugar?
34. Have you had a flu shot since July 1, 2014?

31a. A heart attack?
31b. Angina or coronary heart disease?
31c. A stroke
NO SUCH RESPONSE OPTION
31d. Cancer, other than skin cancer?
31e. Emphysema, asthma or COPD (chronic
obstructive pulmonary disease)?
31f. Any kind of diabetes or high blood sugar?
32. Have you had a flu shot since September 1,
2011?
33. 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.
34. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
35. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider?
36. What is your age?
37. Are you male or female?
38. What is the highest grade or level of school
that you have completed?
39. Are you of Hispanic or Latino origin or
descent?
40. What is your race? Please mark one or more

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.
36. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
37. In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider?
No comparable question.
No comparable question.
38. What is the highest grade or level of school
that you have completed?
39. Are you of Hispanic or Latino origin or
descent?
40. What is your race? Please mark one or more.
41. How many people live in your household now,
including yourself?

No comparable question
31. Has a doctor ever told you that you had any of
the following conditions?

No comparable question

Survey Section

Proposed Question

Existing Question

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?
43. Did someone help you complete this survey?
44. How did that person help you? Please mark
one or more.

44. 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?
41. Did someone help you complete this survey?
42. How did that person help you? Please mark
one or more.

44a. Read the questions to me
44b. Wrote down the answers I gave
44c. Answered the questions for me
44d. Translated the questions into my language
44e. Helped in some other way
No comparable question

42a. Read the questions to me
42b. Wrote down the answers I gave
42c. Answered the questions for me
42d. Translated the questions into my language
42e. Helped in some other way
43. Do you live alone?