Cms-p-0015a Mcbs

AC1
 Allergy/immunology (allergies, asthma)
 Anesthesiology
 Cardiology (heart)
 Dermatology (skin)
 Endocrinology/metabolism (diabetes, thyroid)
 Family practice
 Gastroenterology
 General practice
 General surgery
 Geriatrics (elderly)
 Gynecology – obstetrics
 Hematology (blood)
 Hospital residence
 Internal medicine (internist)
 Nephrology (kidneys)
 Neurology (nervous system)

Updated August 3, 2016

(continued)

AC1
 Nuclear medicine
 Oncology (tumors, cancer)
 Ophthalmology (eyes)
 Orthopedics (bones, joints)
 Osteopathy (DO)
 Otorhinolaryngology (ear, nose, throat)
 Pain Management Specialist
 Pathology
 Physical med/rehab
 Physician’s Assistant
 Plastic surgery
 Podiatrist (ankle, foot)
 Proctology
 Psychiatry/psychiatrist (mental health)
 Pulmonary (lungs)
(continued)

Updated August 3, 2016

AC1
 Radiology
 Rheumatology (arthritis)
 Thoracic surgery (chest)


Urology (urinary tract)



Vascular Surgeon/Specialist (arteries, veins,
lymphatic systems)

Updated August 3, 2016

DI1
 Mexican, Mexican American, Chicano(a)
 Puerto Rican
 Cuban

Updated July 28, 2014

DI2
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or other Pacific Islander
 White

Updated July 28, 2014

DI3
 Asian Indian
 Chinese
 Filipino
 Japanese
 Korean
 Vietnamese

Updated July 28, 2014

DI4
 Native Hawaiian
 Guamanian or Chamorro
 Samoan

Updated July 28, 2014

DI5
 No schooling completed
 Nursery school to 8th grade
 9th-12th grade, no diploma
 High school graduate (high school
diploma or the equivalent)
 Vocational/technical/business/trade
school certificate or diploma (beyond the
high school level)
 Some college, but no degree
 Associate degree
 Bachelor's degree
 Master's, professional, or doctorate
degree
Updated July 28, 2014

DI6
Annual Income

Monthly Breakdown

A. Less than $5,000

A. Less than $417

B. $5,000 – less than $10,000

B. $417 – less than $834

C. $10,000 – less than $15,000

C. $834 – less than $1,250

D. $15,000 – less than $20,000

D. $1,250 – less than $1,667

E. $20,000 – less than $25,000

E. $1,667 – less than $2,084

F. $25,000 – less than $30,000

F. $2,084 – less than $2,500

G. $30,000 – less than $40,000

G. $2,500 – less than $3,334

H. $40,000 – less than $50,000

H. $3,334 – less than $4,167

I.

$50,000 – less than $66,000

I.

$4,167 – less than $5,500

J.

$66,000 – less than $109,000

J.

$5,500 – less than $9,084

K. $109,000 or more

K. $9,084 or more
Updated August 1, 2015

DU1
 General exam, checkup or consultation
 Cleaning, prophylaxis, or polishing
 X-rays, radiographs, or bitewings
 Fluoride treatment
 Sealant (plastic coatings on back teeth)
 Fillings
 Inlays
 Crowns or caps
 Root canal
 Periodontal scaling, root planing, or gum
surgery
 Periodontal recall visit (periodic or
regular)

(continued)
Updated August 1, 2015

DU1
 Extraction, tooth pulled
 Implants
 Abscess or infection treatment
 Other oral surgery
 Fixed bridges
 Dentures or removable partial dentures
 Relining or repair of bridges or dentures
 Orthodontia, braces, or retainers
 Bond, whiten, or bleach
 Treatment for TMD or TMJ

Updated August 1, 2015

ENS1
 Iraq or Afghanistan Conflict (2001 –
Present)
 Persian Gulf War (Aug 1990 – March
1991)
 Vietnam Era (Aug 1964 – May 1975)
 Korean Conflict (June 1950 – Jan 1955)
 World War II (Sept 1940 – July 1947)
 World War I (1917 – 1918)
 Peace time (all other times)

Updated July 28, 2014

HA1
 One-family, detached
 Two-family or duplex
 Apartment or condominium building
 Mobile home, trailer
 Rowhouse, townhouse
 “mother-in-law” apartment

Updated July 28, 2014

HA2
 Retirement community
 Senior citizens housing
 Assisted living facility
 Continuing care community
 Staged living community
 Retirement apartments
 Church-provided housing
 Personal or residential care home

Updated July 28, 2014

HA3
 Prepared meals
 Housekeeping, maid, or cleaning services
 Laundry services
 Help with medications
 Transportation
 Recreational services

Updated July 28, 2014

HF1
 Much better now than one year ago
 Somewhat better now than one year ago
 About the same
 Somewhat worse now than one year ago
 Much worse now than one year ago

Updated August 1, 2015

HF2
 It will get much better
 It will get somewhat better
 It will not change
 It will get somewhat worse
 It will get much worse

Updated August 1, 2015

HF3
 No difficulty at all
 A little difficulty
 Some difficulty
 A lot of difficulty
 Not able to do it

Updated August 1, 2015

HF4
 Bladder
 Blood
 Bone
 Brain
 Breast
 Cervix
 Colon (bowel)
 Esophagus
 Gall Bladder
 Kidney
 Larynx (windpipe)
 Leukocytes (Leukemia)
 Liver
(continued)
Updated August 3, 2016

HF4
 Lung
 Lymph Nodes (Lymphoma)
 Mouth/Tongue/Lip
 Ovary
 Pancreas
 Prostate
 Rectum
 Soft Tissue/Fat
 Stomach
 Testis
 Throat
 Thyroid
 Uterus
Updated August 3, 2016

HF5
 Type 1
 Type 2
 Borderline
 Pre-Diabetes
 Gestational (Pregnancy-related)

Updated August 3, 2016

HF6
 All of the time
 Most of the time
 Some of the time
 A little of the time
 None of the time

Updated August 3, 2016

HF7
 Just about everything you need to know
 Most of what you need to know
 Some of what you need to know
 A little of what you need to know
 Almost none of what you need to know
about managing Diabetes

Updated August 3, 2016

HF9
HF8
 Not at all
 Several days
 More than half the days
 Nearly every day

Updated August 3, 2016

HF10
HF9
HF8
 Not at all difficult
 Somewhat difficult
 Very difficult
 Extremely difficult

Updated August 3, 2016

HF10
 More than one a week
 About once a week
 2-3 times a month
 About once a month
 Every 2-3 months
 Once or twice a year
 Not at all

Updated August 3, 2016

HH1
Home Help by Health or Medical
Professionals
 Nurse (visiting nurse, private duty nurse,
etc.)
 Doctor
 Social worker
 Therapist
 Hospice worker

Updated July 28, 2014

HH2
Medical or Nursing Treatment
 Applying sterile bandages or dressings
 Giving medications
 Taking blood pressure
 Giving shots or injections

Updated July 28, 2014

HH3
Help With Daily Needs
 Using the telephone
 Doing housework
 Preparing meals

Updated July 28, 2014

HH4
 Bathing
 Showering
 Dressing
 Eating
 Walking
 Using the toilet

Updated July 28, 2014

HH5
Personal Care or Help with Daily Needs
from Persons Who Do Not Live with You
 Home health aides
 Homemakers
 Friends
 Neighbors
 Relatives

Updated July 28, 2014

HI1
Health Insurance Coverage Options
 “Original” Medicare
 “Medicare Advantage” (MA) plan
o with Prescription Drug Plan (MA-PD) or
without
 Medicaid
 TRICARE/TRICARE for Life
 Public Programs (other than Medicaid)
 Medicare Part D Prescription Drug Plan (PDP)
 Private/Supplemental Insurance Plan
o Purchased directly from an insurance
company, or
o Obtained through an employer, union, or
other group, such as AARP

Updated February 17, 2015

HI1
ORIGINAL MEDICARE

MEDICARE ADVANTAGE

 You have your choice of doctors and hospitals.
 Generally, you or your supplemental coverage pay
deductibles and coinsurance.
 If you want drug coverage, you must join a standalone Medicare prescription drug plan –a
separate policy just for drugs.
 You can buy a Medigap plan, which can help pay
expenses not covered by Medicare.

 May either require you to see medical providers in
their network or let you choose and pay more of
the costs.
 You usually pay a copay or coinsurance for
covered services.
 If you want drug coverage, you must join a plan that
includes drug coverage. This will give you all of
your coverage in one plan.
 A Medigap plan is not available.

MEDICAID

TRICARE/TRICARE FOR LIFE

 Public health care plan that helps make Medicare
affordable for beneficiaries with low incomes and
modest assets.
 Medicare beneficiaries who are also enrolled in
Medicaid are referred to as “dual eligibles.”
 Will be automatically enrolled in a Medicare
prescription drug plan and be eligible for a lowincome subsidy or “extra help.”

 Covers active-duty service members, retirees, and
their families.
 TRICARE generally pays the fees left outstanding
after Medicare has made their payment.

Updated February 17, 2015

(continued)

HI1
PRIVATE SUPPLEMENTAL INSURANCE
 Separate plans that help pay for Medicare
deductibles and coinsurance, and/or provide
coverage for services not covered under Medicare.
 Available to beneficiaries who are covered by
Original Medicare.
 Obtained from previous employers, private
companies, union, associations, and other groups.

MEDICARE PART D PRESCRIPTION DRUG PLAN
 Separate policies that cover only prescribed
medicines.
 Beneficiaries pay a monthly premium and copay or
coinsurance for their required prescriptions.
 Standalone plans are only available to beneficiaries
who are covered by Original Medicare; otherwise
drug coverage is available as part of Medicare
Advantage plans.

PUBLIC PROGRAMS (OTHER THAN MEDICAID)
 Include state, county, or city-based programs such as a pharmacy program, where the local government
provides at least partial coverage for the cost of prescribed medicines.
 Insurance comes from a public source other than Medicare or Medicaid.

Updated February 17, 2015

HIT1
TRICARE Plan Names
A. TRICARE for Life
B. TRICARE Plus
C. TRICARE Prime
D. TRICARE Extra
E. TRICARE Standard
F. TRICARE Pharmacy / TRICARE Senior
Pharmacy
G. TRICARE Dental Program
H. TRICARE Retiree Dental Program
I. TRICARE Reserve Select (TRS)
J. TRICARE US Family Health Plan
(continued)
Updated July 28, 2014

HIT1

Beneficiary Information Card
for TRICARE For Life

FRONT OF CARD 

TRICARE For Life
To Provider: File claims in the usual manner to Medicare.
To Patient : Services that are a benefit of both Medicare and
TRICARE :No deductible or cost share is required.
Medicare only benefit :Medicare deductible and
cost share required.
TRICARE only benefit:TRICARE deductible and
cost share required.
For benefit questions call 1-888-DoD-LIFE

(1-888-363-5433)

www.tricare.osd.mil

For more information call 1-800-977-6753

www.hnfs.net

BACK OF CARD 

TRICARE Senior Pharmacy
Military Treatment Facility: No Co-pay
National Mail Order Pharmacy: $3 generic;$9 brand name
(90 day supply)

TRICARE Network Pharmacy: $3 generic;$9 brand name
(30 day supply)

TRICARE Non-network Pharmacy: $9 or 20%of cost (30 day supply)
$150/person or $300/family
annual deductible applies.
For pharmacy questions call 1-877-DoD-MEDS

(1-877-363-6337)

(Co-pays subject to change)
5007334 (9/01 T85)

Updated July 28, 2014

HIT2
Places to Obtain Medicines in Tricare
Plan
 TRICARE Mail Order Pharmacy (TMOP)
 TRICARE Retail Pharmacy Network
Pharmacy (TRRx)
 Military Treatment Facility Pharmacy
(MTF)
 Non-network retail pharmacy

Updated July 28, 2014

IA1
Monthly Mortgage Payments
A. Less than $250
B. $250 – less than $500
C. $500 – less than $1,000
D. $1,000 – less than $3,000
E. $3,000 – less than $5,000
F. $5,000 or more

Updated August 1, 2015

IA2
Present Value of
Home/Apartment/Condo
A. Less than $50,000
B. $50,000 – less than $75,000
C. $75,000 – less than $100,000
D. $100,000 – less than $200,000
E. $200,000 – less than $300,000
F. $300,000 – less than $500,000
G. $500,000 – less than $750,000

H. $750,000 or more

Updated August 1, 2015

IA3
Monthly Rent
A. Less than $250
B. $250 – less than $500
C. $500 – less than $1,000
D. $1,000 – less than $3,000
E. $3,000 – less than $5,000
F. $5,000 or more

Updated August 1, 2015

IA4
Retirement Plans
 401(k)
 403(b)
 IRA
 Keogh

Updated August 1, 2015

IA5
Combined Monthly Social
Security or Railroad Retirement
Amount
A. Less than $1,300
B. $1,300 – less than $1,700
C. $1,700 – less than $2,200
D. $2,200 – less than $2,600
E. $2,600 or more

Updated August 1, 2015

IA6
Individual Monthly Social
Security or Railroad
Retirement Amount
A. Less than $700
B. $700 – less than $1,000
C. $1,000 – less than $1,300
D. $1,300 – less than $1,600
E. $1,600 or more

Updated August 1, 2015

IA7
Combined Monthly
Supplemental Security
Income Amount
A. Less than $300
B. $300 – less than $700
C. $700 – less than $1,000
D. $1,000 or more

Updated August 1, 2015

IA8
Individual Monthly
Supplemental Security
Income Amount
A. Less than $100
B. $100 – less than $200
C. $200 – less than $400
D. $400 – less than $700
E. $700 or more

Updated August 1, 2015

IA9
Combined Monthly Veterans
Administration Income
Amount
A. Less than $1,000
B. $1,000 – less than $1,400
C. $1,400 – less than $1,800
D. $1,800 – less than $2,200
E. $2,200 or more

Updated August 1, 2015

IA10
Individual Monthly Veterans
Administration Income
Amount
A. Less than $500
B. $500 – less than $700
C. $700 – less than $900
D. $900 – less than $1,100
E. $1,100 or more

Updated August 1, 2015

IA11
Combined Monthly Pension
Payment
A. Less than $600
B. $600 – less than $1,300
C. $1,300 – less than $2,100
D. $2,100 – less than $5,900
E. $5,900 or more

Updated August 1, 2015

IA12
Individual Monthly Pension
Payment
A. Less than $400
B. $400 – less than $900
C. $900 – less than $1,600
D. $1,600 – less than $3,800
E. $3,800 or more

Updated August 1, 2015

IA13
Combined Total Retirement
Accounts
A. Less than $34,000
B. $34,000 – less than $82,000
C. $82,000 – less than $175,000
D. $175,000 – less than $413,000
E. $413,000 or more

Updated August 1, 2015

IA14
Individual Total Retirement
Accounts
A. Less than $20,000
B. $20,000 – less than $47,000
C. $47,000 – less than $92,000
D. $92,000 – less than $218,000
E. $218,000 or more

Updated August 1, 2015

IA15
Combined Monthly Amount
Received from Retirement
Account
A. Less than $200
B. $200 – less than $500
C. $500 – less than $1,000
D. $1,000 – less than $2,500
E. $2,500 or more

Updated August 1, 2015

IA16
Individual Monthly Amount
Received from Retirement
Account
A. Less than $100
B. $100 – less than $300
C. $300 – less than $700
D. $700 – less than $1,700
E. $1,700 or more

Updated August 1, 2015

IA17
Combined Amount Received
from Retirement Account Last
Year
A. Less than $2,400
B. $2,400 – less than $6,000
C. $6,000 – less than $12,000
D. $12,000 – less than $30,000
E. $30,000 or more

Updated August 1, 2015

IA18
Individual Amount Received
from Retirement Account Last
Year
A. Less than $1,200
B. $1,200 – less than $3,600
C. $3,600 – less than $8,400
D. $8,400 – less than $20,400
E. $20,400 or more

Updated August 1, 2015

IA19
Combined Mutual
Funds/Stocks/Bonds Not Part
of Retirement Account
A. Less than $9,000
B. $9,000 – less than $18,000
C. $18,000 – less than $93,000
D. $93,000 – less than $350,000
E. $350,000 or more

Updated August 1, 2015

IA20
IAQ35C- Mutual
Funds/Stocks/Bonds Not Part
of Retirement Account
A. Less than $600
B. $600 – less than $5,000
C. $5,000 – less than $16,000
D. $16,000 – less than $62,000
E. $62,000 or more

Updated August 1, 2015

IA21
IAC26A- Mutual
Funds/Stocks/Bonds Not Part
of Retirement Account
A. Less than $8,000
B. $8,000 – less than $62,000
C. $62,000 – less than $192,000
D. $192,000 – less than $213,000
E. $213,000 or more

Updated August 1, 2015

IA22
IAQ36C- Mutual
Funds/Stocks/Bonds Not Part
of Retirement Account
A. Less than $300
B. $300 – less than $2,500
C. $2,500 – less than $8,000
D. $8,000 – less than $37,000
E. $37,000 or more

Updated August 1, 2015

IA23
IAQ38B – All Accounts Last
Month
A. Less than $11,000
B. $11,000 – less than $25,000
C. $25,000 – less than $50,000
D. $50,000 – less than $108,000
E. $108,000 or more

Updated August 1, 2015

IA24
IAQ38C – All Accounts Last
Month
A. Less than $2,000
B. $2,000 – less than $7,000
C. $7,000 – less than $17,000
D. $17,000 – less than $57,000
E. $57,000 or more

Updated August 1, 2015

IA25
IAQ39B/IAQ40B – All Accounts
Last Month
A. Less than $8,000
B. $8,000 – less than $13,000
C. $13,000 – less than $28,000
D. $28,000 – less than $54,000
E. $54,000 or more

Updated August 1, 2015

IA26
IAQ39C/IAQ40C – All Accounts
Last Month
A. Less than $500
B. $500 – less than $1,900
C. $1,900 – less than $5,000
D. $5,000 – less than $20,000
E. $20,000 or more

Updated August 1, 2015

IA27
IAQ41 – Combined Interest and
Dividends Last Year
A. Less than $200
B. $200 – less than $1,000
C. $1,000 – less than $4,000
D. $4,000 – less than $16,000
E. $16,000 or more

Updated August 1, 2015

IA28
IAQ42B/IAQ43B – Individual
Interest and Dividend Income
A. Less than $400
B. $400 – less than $1,000
C. $1,000 – less than $2,000
D. $2,000 – less than $11,000
E. $11,000 or more

Updated August 1, 2015

IA29
IAQ44A – Value of Business,
Farm, or Real Estate
A. Less than $30,000
B. $30,000 – less than $101,000
C. $101,000 – less than $247,000
D. $247,000 – less than $703,000
E. $703,000 or more

Updated August 1, 2015

IA30
IAQ45B/IAQ46A – Value of
Business, Farm, or Real Estate
A. Less than $18,000
B. $18,000 – less than $68,000
C. $68,000 – less than $122,000
D. $122,000 – less than $293,000
E. $293,000 or more

Updated August 1, 2015

IA31
IAQ47B – Income from
Businesses or Property
A. Less than $3,600
B. $3,600 – less than $12,000
C. $12,000 – less than $25,000
D. $25,000 – less than $64,000
E. $64,000 or more

Updated August 1, 2015

IA32
IAQ48B/IAQ49B – Income from
Businesses or Property
A. Less than $3,600
B. $3,600 – less than $7,200
C. $7,200 – less than $14,000
D. $14,000 – less than $38,000
E. $38,000 or more

Updated August 1, 2015

IA33
IAQ51A – Total Income
A. Less than $30,000
B. $30,000 – less than $43,000
C. $43,000 – less than $66,000
D. $66,000 – less than $109,000
E. $109,000 or more

Updated August 1, 2015

IA34
IAQ51B – Total Income
A. Less than $18,000
B. $18,000 – less than $22,000
C. $22,000 – less than $36,000
D. $36,000 – less than $56,000
E. $56,000 or more

Updated August 1, 2015

IA35
Lump Sum Payments
A. Insurance Settlement
B. Pension Settlement
C. Inheritance (or Trust)
D. Gift
E. Lawsuit

Updated May 4, 2016

IA36
Present Value of Vehicles
A. Less than $2,500
B. $2,500 – less than $5,000
C. $5,000 – less than $7,500
D. $7,500 – less than $10,000
E. $10,000 – less than $20,000
F. $20,000 or more

Updated May 4, 2016

IU1
Long Term Care Places
 Skilled nursing homes
 Intermediate care facilities
 Board and care homes
 Nursing home units in hospitals
 Facilities for the mentally retarded
 Psychiatric facilities
 Group homes

Updated July 28, 2014

KN1
 Very easy
 Somewhat easy
 Somewhat difficult
 Very difficult

Updated July 28, 2014

KN2
 Just about everything you need to know
 Most of what you need to know
 Some of what you need to know
 A little of what you need to know
 Almost none of what you need to know

Updated July 28, 2014

KN3
 Very interested
 Somewhat interested
 Not very interested
 Not at all interested

Updated January 13, 2016

KN4
 At least once every year
 Once every few years
 Rarely
 Never
 Only once when first signed up for drug
plan
 Only once when first signed up for
Medicare
 Just signed up for Medicare

Updated January 13, 2016

KN5
 Completely agree
 Somewhat agree
 Somewhat disagree
 Completely disagree

Updated January 13, 2016

KN6
 Very satisfied
 Satisfied
 Dissatisfied
 Very Dissatisfied

Updated January 13, 2016

KN7

Updated January 13, 2016

MP1
Health Practitioners Who Are Not
Medical Doctors
 Acupuncturist
 Audiologist
 Optometrist
 Chiropractor
 Podiatrist (foot doctor)
 Homeopath
 Naturopath
 Any other kind of health provider who is
not a medical doctor

Updated July 28, 2014

MP2
Mental Health Professionals
 Psychiatrist
 Psychologist
 Clinical social worker
 Licensed professional counselor

Updated July 28, 2014

MP3
Therapists
 Physical therapist
 Speech therapist
 (Intravenous) I.V. therapist
 Massage therapist
 Occupational therapist
 Respiratory therapist

Updated July 28, 2014

MP4
Other Medical Persons
 Nurse
 Nurse practitioner
 Paramedic (not including ambulance
services)
 Physician's assistant

Updated July 28, 2014

MP5
Other Types of Medical Places
 Health clinic
 Neighborhood health center
 Rural health clinic
 Infirmary
 Mental health clinic
 Urgent care center
 Any other place

Updated July 28, 2014

NA1
 12 oz. beer
 5 oz. glass of wine
 One and a half ounces of liquor

Updated August 3, 2016

OM1
Orthopedic Items
 Crutches
 Canes
 Wheelchairs
 Walkers
 Corrective shoes or inserts
 Support stockings
 Braces or supports

Updated July 28, 2014

OM2
Diabetic Equipment or Supplies
 Syringes
 Test paper
 Test strips
 Blood monitoring kits

Updated July 28, 2014

OM3
Prostheses
 Artificial leg or arm
 Mastectomy prosthesis
 Artificial or glass eye

Updated July 28, 2014

OM4
Other Medical Equipment and Supplies
 Portable commode or raised toilet seat
 Portable tub seat
 Special chair or cushion
 Hospital bed
 Ostomy supplies
 Incontinence supplies (such as depends,
serenity or other brands of disposable
undergarments, pads, or briefs)
 Bandages, dressings, tape supplies
 Pulmonary equipment (nebulizer, CPAP, etc.)

 Blood pressure equipment (such as cuffs or
monitors)

Updated July 28, 2014

OM5
Alterations Inside or Outside Home or
Car
 Ramps
 Handrails (other than tub handrails)
 Elevator or incline chair
 Tub seats
 Tub handrails
 Any car alteration

Updated July 28, 2014

PM1
 Often
 Sometimes
 Never

Updated July 28, 2014

RX1
 Very easy
 Somewhat easy
 Somewhat difficult
 Very difficult

Updated July 28, 2014

RX2
 Just about everything you need to know
 Most of what you need to know
 Some of what you need to know
 A little of what you need to know
 Almost none of what you need to know

Updated July 28, 2014

RX3
 Very satisfied
 Satisfied
 Dissatisfied
 Very dissatisfied

Updated July 28, 2014

RX4
 Extremely confident
 Very confident
 Moderately confident
 Slightly confident
 Not confident

Updated July 28, 2014

SC1
 Very satisfied
 Satisfied
 Dissatisfied
 Very dissatisfied

Updated July 28, 2014

SC2
 Didn't think the problem was serious
 Thought it would cost too much
 Trouble finding or getting to the doctor
 Time, schedule, or personal conflicts
 Thought doctor couldn’t do much about
the problem
 Was afraid of finding out what was wrong
 Doctor would not accept my insurance

Updated July 28, 2014

SC3
 Thought it would cost too much
 Didn’t think medicine would help the
condition
 Was afraid of medicine reactions or
contraindications
 Don’t like to take medicine
 Didn’t think medicine was necessary
 The medicine was not covered by
insurance or not on the plan’s formulary
 Trouble obtaining medicine
 Obtained or used samples
 Used another medicine as a substitution

Updated July 28, 2014

SC4
 Often
 Sometimes
 Never

Updated July 28, 2014

US1
 Less than 1 year
 1 year to less than 3 years
 3 years to less than 5 years
 5 years to less than 10 years
 10 years or more

Updated July 28, 2014

US2
 Never
 Sometimes
 Usually
 Always

Updated July 28, 2014

US3
 Strongly agree
 Agree
 Disagree
 Strongly disagree

Updated August 1, 2015