Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

[2019 EOC model]

January 1 – December 31, 2019

Evidence of Coverage:

Your Medicare Prescription Drug Coverage as a Member of [insert 2019 plan name][insert plan type]

[Optional: insert beneficiary name]
[Optional: insert beneficiary address]

This booklet gives you the details about your Medicare prescription drug coverage from January 1 – December 31, 2019. It explains how to get coverage for the prescription drugs you need. This is an important legal document. Please keep it in a safe place.

This plan, [insert 2019 plan name], is offered by [insert Part D sponsor name]. (When this Evidence of Coverage says “we,” “us,” or “our,” it means [insert Part D sponsor name]. When it says “plan” or “our plan,” it means [insert 2019 plan name].)

[Insert Federal contracting statement.]

[Plans that meet the 5% alternative language threshold insert: This document is available for free in [insert languages that meet the 5% threshold].

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].]

[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, premium, deductible, and/or copayments/coinsurance may change on January 1, 2020.

[Remove terms as needed to reflect plan benefits] The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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

2019 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 4

Explains what it means to be in a Medicare prescription drug plan and how to use this booklet. Tells about materials we will send you, your plan premium, the Part D late enrollment penalty, your plan membership card, and keeping your membership record up to date.

Chapter 2. Important phone numbers and resources 22

Tells you how to get in touch with our plan ([insert 2019 plan name]) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board.

Chapter 3. Using the plan’s coverage for your Part D prescription drugs 40

Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan’s programs for drug safety and managing medications.

Chapter 4. What you pay for your Part D prescription drugs 66

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

Chapter 5. Asking us to pay our share of the costs for covered drugs 89

Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered drugs.

Chapter 6. Your rights and responsibilities 96

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

Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 106

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 prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules and/or extra restrictions on your coverage.

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

Chapter 8. Ending your membership in the plan 132

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

Chapter 9. Legal notices 142

Includes notices about governing law and about non-discrimination.

Chapter 10. Definitions of important words 145

Explains key terms used in this booklet.

Chapter 1

Getting started as a member

Chapter 1. Getting started as a member

SECTION 1 Introduction 6

Section 1.1 You are enrolled in [insert 2019 plan name], which is a Medicare Prescription Drug Plan 6

Section 1.2 What is the Evidence of Coverage booklet about? 6

Section 1.3 Legal information about the Evidence of Coverage 6

SECTION 2 What makes you eligible to be a plan member? 7

Section 2.1 Your eligibility requirements 7

Section 2.2 What are Medicare Part A and Medicare Part B? 7

Section 2.3 Here is the plan service area for [insert 2019 plan name] 7

Section 2.4 U.S. Citizen or Lawful Presence 8

SECTION 3 What other materials will you get from us? 8

Section 3.1 Your plan membership card – Use it to get all covered prescription drugs 8

Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network 9

Section 3.3 The plan’s List of Covered Drugs (Formulary) 10

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs 10

SECTION 4 Your monthly premium for [insert 2019 plan name] 11

Section 4.1 How much is your plan premium? 11

SECTION 5 Do you have to pay the Part D “late enrollment penalty”? 12

Section 5.1 What is the Part D “late enrollment penalty”? 12

Section 5.2 How much is the Part D late enrollment penalty? 13

Section 5.3 In some situations, you can enroll late and not have to pay the penalty 13

Section 5.4 What can you do if you disagree about your Part D late enrollment penalty? 14

SECTION 6 Do you have to pay an extra Part D amount because of your income? 14

Section 6.1 Who pays an extra Part D amount because of income? 14

Section 6.2 How much is the extra Part D amount? 15

Section 6.3 What can you do if you disagree about paying an extra Part D amount? 15

Section 6.4 What happens if you do not pay the extra Part D amount? 15

SECTION 7 More information about your monthly premium 15

Section 7.1 There are several ways you can pay your plan premium 16

Section 7.2 Can we change your monthly plan premium during the year? 18

SECTION 8 Please keep your plan membership record up to date 18

Section 8.1 How to help make sure that we have accurate information about you 18

SECTION 9 We protect the privacy of your personal health information 19

Section 9.1 We make sure that your health information is protected 19

SECTION 10 How other insurance works with our plan 20

Section 10.1 Which plan pays first when you have other insurance? 20

SECTION 1 Introduction

Section 1.1 You are enrolled in [insert 2019 plan name], which is a Medicare Prescription Drug Plan

You are covered by Original Medicare for your health care coverage, and you have chosen to get your Medicare prescription drug coverage through our plan, [insert 2019 plan name].

There are different types of Medicare plans. [Insert 2019 plan name] is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and run by a private company.

Section 1.2 What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare prescription drug coverage through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan.

The word “coverage” and “covered drugs” refers to the prescription drug coverage available to you as a member of [insert 2019 plan name].

It’s important for you to learn what the plan’s rules are and what coverage is available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet.

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

Section 1.3 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 2019 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 2019 plan name] between January 1, 2019, and December 31, 2019.

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 2019 plan name] after December 31, 2019. We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2019.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services) must approve [insert 2019 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 have Medicare Part A or Medicare Part B (or you have both Part A and Part B) (Section 2.2 tells you about Medicare Part A and Medicare Part B)

• -- and -- you are a United States citizen or are lawfully present in the United States

• -- and -- you live in our geographic service area (Section 2.3 below describes our service area) [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 are still eligible as long as you have not moved since before January 1999.]

Section 2.2 What are Medicare Part A and Medicare Part B?

As discussed in section 1.1 above, you have chosen to get your prescription drug coverage (sometimes called Medicare Part D) through our plan. Our plan has contracted with Medicare to provide you with most of these Medicare benefits. We describe the drug coverage you receive under your Medicare Part D coverage in Chapter 3.

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 (DME) and supplies).

Section 2.3 Here is the plan service area for [insert 2019 plan name]

Although Medicare is a Federal program, [insert 2019 plan name] is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described [insert as appropriate: below OR in an appendix to this Evidence of Coverage].

[Insert plan service area here or within an appendix. Plans may include references to territories as appropriate. Examples of the format for describing the service area are provided below:
Our service area includes all 50 states
Our service area includes these states: [insert states]]

[Optional info: multi-state plans may include the following: We offer coverage in [insert as applicable: several OR all] states [insert if applicable: and territories]. However, there may be cost or other differences between the plans we offer in each state. If you move out of state [insert if applicable: or territory] and into a state [insert if applicable: or territory] that is still within our service area, you must call Member Services in order to update your information. [National plans delete the rest of this paragraph.] If you move into a state [insert if applicable: or territory] outside of our service area, you cannot remain a member of our plan. Please call Member Services to find out if we have a plan in your new state [insert if applicable: or territory].]

If you plan to move out of the service area, please contact Member Services (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to enroll in a Medicare health or drug plan that is available in your new location.

It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Section 2.4 U.S. Citizen or Lawful Presence

A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify [insert 2019 plan name] if you are not eligible to remain a member on this basis. [Insert 2019 plan name] must disenroll you if you do not meet this requirement.

SECTION 3 What other materials will you get from us?

Section 3.1 Your plan membership card – Use it to get all covered prescription drugs

While you are a member of our plan, you must use your membership card for our plan for prescription drugs you get at network pharmacies. You should also show the provider your Medicaid card, if applicable. 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.]

Please carry your card with you at all times and remember to show your card when you get covered drugs. If your plan membership card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. (Phone numbers for Member Services are printed on the back cover of this booklet.)

You may need to use your red, white, and blue Medicare card to get covered medical care and services under Original Medicare.

Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network

What are “network pharmacies”?

Network pharmacies are 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. [Insert applicable section: For a plan that has changes in its pharmacy network] There are changes to our network of pharmacies for next year. [Insert if applicable: We included a copy of our Pharmacy Directory in the envelope with this booklet.] 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 2019 Pharmacy Directory to see which pharmacies are in our network. 

OR

[For a plan that will have a higher than normal number of pharmacies leaving its pharmacy network] Our network has changed more than usual for 2019. [Insert if applicable: We included a copy of our Pharmacy Directory in the envelope with this booklet.] 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. We strongly suggest that you review our current Pharmacy Directory to see if your pharmacy is still in our network. This is important because, with few exceptions, you must get your prescriptions filled at a network pharmacy 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 for some drugs.]

If you don’t have the Pharmacy Directory, you can get a copy from Member Services (phone numbers are printed on the back cover of this booklet). At any time, you can call Member Services to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at [insert URL]. [Plans may add detail describing additional information about network pharmacies available from Member Services or on the website.]

Section 3.3 The plan’s List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered by [insert 2019 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 2019 plan name] Drug List.

The Drug List also tells you if there are any rules that restrict coverage for your drugs.

We will provide you a copy of the Drug List. [Insert if applicable: The Drug List we provide 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 provided Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Member Services to find out if we cover it.] To get the most complete and current information about which drugs are covered, you can visit the plan’s website ([insert URL]) or call Member Services (phone numbers are printed on the back cover of this booklet).

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the “Part D EOB”).

The Part D Explanation of Benefits tells you the total amount you, 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 4 (What you pay for your Part D prescription drugs) gives more information about the Part D Explanation of Benefits and how it can help you keep track of your drug coverage.

A Part D Explanation of Benefits summary is also available upon request. To get a copy, please contact Member Services (phone numbers are printed on the back cover of this booklet).

[Note: Plans may insert other methods that members can get their Part D Explanation of Benefits.]

SECTION 4 Your monthly premium for [insert 2019 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 2019, the monthly premium for [insert 2019 plan name] is [insert monthly premium amount]. OR The table below shows the monthly plan premium amount for each region we serve. OR The table below shows the monthly plan premium amount for each plan we are offering in the service area. OR The monthly premium amount for [insert 2019 plan name] is listed in [describe attachment]. [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].] 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).

[Insert if applicable: Your coverage is provided through a contract with your current employer or former employer or union. Please contact the employer’s or union’s benefits administrator for information about your plan premium.]

In some situations, your plan premium could be less

[Insert as appropriate, depending on whether SPAPs are discussed in Chapter 2: There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. OR The “Extra Help” program helps people with limited resources pay for their drugs.] Chapter 2, Section 7 tells more about [insert as applicable: these programs OR this program]. If you qualify, enrolling in the program might lower your monthly plan premium.

If you are already enrolled and getting help from one of these programs, the information about premiums in this Evidence of Coverage [insert as applicable: may OR does] not apply to you. [If not applicable, omit information about the LIS Rider.] We [insert as appropriate: have included OR sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Member Services and ask for the “LIS Rider.” (Phone numbers for Member Services are printed on the back cover of this booklet.)

In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount listed above in Section 4.1. Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn’t have “creditable” prescription drug coverage. (“Creditable” means the drug coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) For these members, the Part D 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 Part D late enrollment penalty.

• If you are required to pay the Part D 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 1, Section 5 explains the Part D late enrollment penalty.

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

SECTION 5 Do you have to pay the Part D “late enrollment penalty”?

Section 5.1 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 Part D 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 Part D late enrollment 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 2019 plan name], we let you know the amount of the penalty.

Your Part D 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 Part D late enrollment penalty, you could be disenrolled for failure to pay your plan premium.]

[Plans with no plan premium, replace the previous two paragraphs with the following language: When you first enroll in [insert 2019 plan name], we let you know the amount of the penalty. Your Part D 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 Part D late enrollment penalty, you could be disenrolled from the plan.]]

Section 5.2 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 2019, this average premium amount is $[insert 2019 national base beneficiary premium] OR For 2018, this average premium amount was $[insert 2018 national base beneficiary premium]. This amount may change for 2019.]

• 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 Part D late enrollment penalty.

There are three important things to note about this monthly Part D 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 Part D late enrollment penalty will reset when you turn 65. After age 65, your Part D 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 5.3 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 Part D late enrollment penalty.

You will not have to pay a penalty for late enrollment if you are in any of these situations:

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

  • 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.

  • The following are not creditable prescription drug coverage: prescription drug discount cards, free clinics, and drug discount websites.

  • For additional information about creditable coverage, please look in your Medicare & You 2019 Handbook or call Medicare at 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.

• 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 5.4 What can you do if you disagree about your Part D late enrollment penalty?

If you disagree about your Part D 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 Part D late enrollment penalty while you’re waiting for a review of the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to pay your plan premiums.]

SECTION 6 Do you have to pay an extra Part D amount because of your income?

Section 6.1 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.

Section 6.2 How much is the extra Part D amount?

If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium. For more information on the extra amount you may have to pay based on your income, visit https://www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html.

Section 6.3 What can you do if you disagree about paying an extra Part D amount?

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

Section 6.4 What happens if you do not pay the extra Part D amount?

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

SECTION 7 More information about your monthly premium

Many members are required to pay other Medicare premiums

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

Some people pay an extra amount for Part D because of their yearly income, this is known Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greater than $[insert amount] for an individual (or married individuals filing separately) or greater than $[insert amount] 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 1, Section 6 of this booklet. You can also visit https://www.medicare.gov on the Web or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Your copy of Medicare & You 2019 gives information about the Medicare premiums in the section called “2019 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 2019 from the Medicare website (https://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.

Section 7.1 There are several ways you can pay your plan premium

There are [insert number of payment options] ways you can pay your plan premium. [Plans must indicate how the member can inform the plan of their premium payment option choice and the procedure for changing that choice.]

If you decide to change the way you pay your premium, it can take up to three months for your new payment method to take effect. While we are processing your request for a new payment method, you are responsible for making sure that your plan premium is paid on time.

Option 1: You can pay by check

[Insert plan specifics regarding premium payment intervals (e.g., monthly, quarterly- please note that beneficiaries must have the option to pay their premiums monthly), how they can pay by check, including an address, whether they can drop off a check in person, and by what day the check must be received (e.g., the 5^th 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.]

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 members who use direct payment electronic payment methods is prohibited.]

[Include the option below only if applicable. SSA only deducts plan premiums below $300.]

Option [insert number]: You can have the plan premium taken out of your monthly Social Security check

You can have the plan premium taken out of your monthly Social Security check. Contact Member Services for more information on how to pay your monthly plan premium this way. We will be happy to help you set this up. (Phone numbers for Member Services are printed on the back cover of this booklet.)

What to do if you are having trouble paying your plan premium

[Plans that do not disenroll members for non-payment may modify this section as needed.]

Your plan premium is due in our office by the [insert day of the month]. If we have not received your premium by the [insert day of the month], we will send you a notice telling you that your plan membership will end if we do not receive your premium payment within [insert length of plan grace period].

If you are having trouble paying your premium on time, please contact Member Services to see if we can direct you to programs that will help with your plan premium. (Phone numbers for Member Services are printed on the back cover of this booklet.)

If we end your membership because you did not pay your premiums, you will still have health coverage under Original Medicare.

If we end your membership with the plan because you did not pay your premiums, and you don’t currently have prescription drug coverage then you may not be able to receive Part D coverage until the following year if you enroll in a new plan during the annual enrollment period. During the annual enrollment period, you may either join a stand-alone prescription drug plan or a health plan that also provides drug coverage. (If you go without “creditable” drug coverage for more than 63 days, you may have to pay a Part D late enrollment penalty for as long as you have Part D coverage.)

[Insert if applicable: At the time we end your membership, you may still owe us for premiums you have not paid. [Insert one or both statements as applicable for the plan: We have the right to pursue collection of the premiums you owe. AND/OR In the future, if you want to enroll again in our plan (or another plan that we offer), you will need to pay the amount you owe before you can enroll.]]

If you think we have wrongfully ended your membership, you have a right to ask us to reconsider this decision by making a complaint. Chapter 7, Section 7 of this booklet tells how to make a complaint. If you had an emergency circumstance that was out of your control and it caused you to not be able to pay your premiums within our grace period, you can ask us to reconsider this decision by calling [insert phone number] between [insert hours of operation]. TTY users should call [insert TTY number]. You must make your request no later than 60 days after the date your membership ends.

Section 7.2 Can we change your monthly plan premium during the year?

No. We are not allowed to change the amount we charge for the plan’s monthly plan premium during the year. If the monthly plan premium changes for next year we will tell you in September and the change will take effect on January 1.

However, in some cases the part of the premium that you have to pay can change during the year. This happens if you become eligible for the “Extra Help” program or if you lose your eligibility for the “Extra Help” program during the year. If a member qualifies for “Extra Help” with their prescription drug costs, the “Extra Help” program will pay part of the member’s monthly plan premium. A member who loses their eligibility during the year will need to start paying their full monthly premium. You can find out more about the “Extra Help” program in Chapter 2, Section 7.

SECTION 8 Please keep your plan membership record up to date

Section 8.1 How to help make sure that we have accurate information about you

[In the heading and this section, plans should substitute the name used for this file if different from “membership record.”]

Your membership record has information from your enrollment form, including your address and telephone number. It shows your specific plan coverage.

The pharmacists in the plan’s network need to have correct information about you. These network providers use your membership record to know what drugs are covered and the cost-sharing amounts for you. Because of this, it is very important that you help us keep your information up to date.

Let us know about these changes:

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

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

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

• If you have been admitted to a nursing home

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

If any of this information changes, please let us know by calling Member Services (phone numbers are printed on the back cover of this booklet). [Plans that allow members to update this information on-line may describe that option here.]

It is also important to contact Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Read over the information we send you about any other insurance coverage you have

[Plans collecting information by phone revise heading and section as needed to reflect process.] That’s because we must coordinate any other coverage you have with your benefits under our plan. (For more information about how our coverage works when you have other insurance, see Section 10 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 9 We protect the privacy of your personal health information

Section 9.1 We make sure that your health information is protected

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

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

SECTION 10 How other insurance works with our plan

Section 10.1 Which plan pays first when you have other insurance?

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

These rules apply for employer or union group health plan coverage:

• If you have retiree coverage, Medicare pays first.

• If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease (ESRD):

  • If you’re under 65 and disabled and you or your family member is still working, your group health 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.

  • If you’re over 65 and you or your spouse is still working, your group health 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.

Chapter 2

Important phone numbers and resources

Chapter 2. Important phone numbers and resources

SECTION 1 [Insert 2019 plan name] contacts (how to contact us, including how to reach Member Services at the plan) 23

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) 29

SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) 30

SECTION 5 Social Security 31

SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources) 32

SECTION 7 Information about programs to help people pay for their prescription drugs 33

SECTION 8 How to contact the Railroad Retirement Board 37

SECTION 9 Do you have “group insurance” or other health insurance from an employer? 38

SECTION 1 [Insert 2019 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 2019 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	[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.]
FAX	[Optional: insert fax number]
WRITE	[Insert address] [Note: plans may add email addresses here.]
WEBSITE	[Insert URL]

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

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 prescription drugs covered under the Part D benefit included in your plan. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

You may call us if you have questions about our coverage decision process.

Method	Coverage Decisions for Part D Prescription Drugs – Contact Information
CALL	[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: If you have different numbers for accepting standard and expedited coverage determinations, 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: 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.] [Note: plans may add email addresses here.]
WEBSITE	[Insert URL]

How to contact us when you are making an appeal about your Part D prescription drugs

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

Method	Appeals for Part D Prescription Drugs – Contact Information
CALL	[Insert phone number] Calls to this number are [insert if applicable: not] free. [Insert days and hours of operation] [Note: You may also include reference to 24-hour lines here.] [Note: You are required to accept expedited appeal requests by phone, and may choose to accept standard appeal requests by phone. If you choose to accept standard appeal requests by phone and you have different numbers for accepting standard and expedited appeals, include both numbers here.]
TTY	[Insert number] [Insert if plan uses a direct TTY number: This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.] Calls to this number are [insert if applicable: not] free. [Insert days and hours of operation] [Note: You are required to accept expedited appeal requests by phone, and may choose to accept standard appeal requests by phone. If you choose to accept standard appeal requests by phone and you have different TTY numbers for accepting standard and expedited appeals, include both numbers here.]
FAX	[Insert fax number] [Note: If you have different fax numbers for accepting standard and expedited appeals, include both numbers here.]
WRITE	[Insert address] [Note: If you have different addresses for accepting standard and expedited appeals, include both addresses here.] [Note: plans may add email 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 your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

Method	Complaints about Part D prescription drugs – Contact Information
CALL	[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: If you have different numbers for accepting standard and expedited grievances, 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: If you have different TTY numbers for accepting standard and expedited grievances, include both numbers here.]
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.] [Note: plans may add email addresses here.]
MEDICARE WEBSITE	You can submit a complaint about [insert 2019 plan name] directly to Medicare. To submit an online complaint to Medicare go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.

Where to send a request asking us to pay for our share of the cost of a drug you have received

The coverage determination process includes determining requests to pay for our share of the costs of a drug that you have received. For more information on situations in which you may need to ask the plan for reimbursement or to pay a bill you have received from a provider, see Chapter 5 (Asking us to pay our share of the costs for covered drugs).

Please note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more information.

Method	Payment Requests – Contact Information
CALL	[Optional: Insert phone number and days and hours of operation] [Note: You are required to accept payment requests in writing, and may choose to also accept payment requests by phone.] Calls to this number are [insert if applicable: not] free.
TTY	[Optional: Insert number] [Note: You are required to accept payment requests in writing, and may choose to also accept payment requests by phone.] [Insert if plan uses a direct TTY number: This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.] Calls to this number are [insert if applicable: not] free. [Insert days and hours of operation]
FAX	[Optional: Insert fax number] [Note: You are required to accept payment requests in writing, and may choose to also accept payment requests by fax.]
WRITE	[Insert address] [Note: plans may add email addresses here.]
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 Prescription Drug Plans, including us.

Method	Medicare – Contact Information
CALL	1-800-MEDICARE, or 1-800-633-4227 Calls to this number are free. 24 hours a day, 7 days a week.
TTY	1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
WEBSITE	https://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.
WEBSITE (continued)	You can also use the website to tell Medicare about any complaints you have about [insert 2019 plan name]: Tell Medicare about your complaint: You can submit a complaint about [insert 2019 plan name] directly to Medicare. To submit a complaint to Medicare, go to https://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 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.)

SECTION 3 State Health Insurance Assistance Program
(free help, information, and answers to your questions about Medicare)

[Organizations offering plans in multiple states: Revise the second and third paragraphs in this section to use the generic name (“State Health Insurance Assistance Program” or “SHIP”), and include a list of names, phone numbers, and addresses for all SHIPs in your service area. Plans have the option of including a separate exhibit to list information for all states in which the plan is filed, and should make reference to that exhibit below.]

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. [Multiple-state plans inserting information in an exhibit, replace rest of this paragraph with a sentence referencing the exhibit where members will find SHIP information.] [Multiple-state plans inserting information in the EOC add: Here is a list of the State Health Insurance Assistance Programs in each state we serve:] [Multiple-state plans inserting information in the EOC use bullets for the following sentence, inserting separate bullets for each state.] In [insert state], the SHIP is called [insert state-specific SHIP name].

[Insert state-specific SHIP name] is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare.

[Insert state-specific SHIP name] counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints 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] [Note: plans may add email addresses here.]
WEBSITE	[Insert URL]

SECTION 4 Quality Improvement Organization
(paid by Medicare to check on the quality of care for people with Medicare)

[Organizations offering plans in multiple states: Revise the second and third paragraphs of this section to use the generic name (“Quality Improvement Organization”) when necessary, and include a list of names, phone numbers, and addresses for all QIOs in your service area. Plans have the option of including a separate exhibit to list the QIOs in all states, or in all states in which the plan is filed, and should make reference to that exhibit below.]

There is a designated Quality Improvement Organization for serving Medicare beneficiaries in 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] if you have a complaint about the quality of care you have received. For example, you can contact [insert state-specific QIO name] if you were given the wrong medication or if you were given medications that interact in a negative way.

Method	[Insert state-specific QIO name] [If the QIO’s name does not include the name of the state, add: ([insert state name]’s Quality Improvement Organization)] – Contact Information
CALL	[Insert phone number(s) and days and hours of operation]
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] [Note: plans may add email addresses here.]
WEBSITE	[Insert URL]

SECTION 5 Social Security

Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and lawful permanent residents 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 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 ET to 7:00 pm, Monday through Friday.
WEBSITE	https://www.ssa.gov/

SECTION 6 Medicaid
(a joint Federal and state program that helps with medical costs for some people with limited income and resources)

[Organizations offering plans in multiple states: Revise this section to include a list of agency names, phone numbers, days and hours of operation, 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) and days and hours of operation]
TTY	[Insert number, if available. Or delete this row.] [Insert if the state Medicaid program uses a direct TTY number: This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.]
WRITE	[Insert address] [Note: plans may add email addresses here.]
WEBSITE	[Insert URL]

SECTION 7 Information about programs to help people pay for their prescription drugs

Medicare’s “Extra Help” Program

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, [insert if applicable: yearly deductible,] and prescription [insert as applicable: copayments OR coinsurance]. This “Extra Help” also counts toward your out-of-pocket costs.

People with limited income and resources may qualify for “Extra Help.” Some people automatically qualify for “Extra Help” and don’t need to apply. Medicare mails a letter to people who automatically qualify for “Extra Help.”

You may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help,” call:

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

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

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

If you believe you have qualified for “Extra Help” and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us.

• [Note: Insert plan’s process for allowing beneficiaries to request assistance with obtaining best available evidence, and for providing this evidence.]

• When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Member Services if you have questions (phone numbers are printed on the back cover of this booklet).

[Plans in U.S. Territories, replace the Extra Help section with the following language if the EOC is used for plans only in the U.S. Territories. Add the following language to the Extra Help section if the EOC is used for plans in the U.S Territories and mainland regions: There are programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa to help people with limited income and resources pay their Medicare costs. Programs vary in these areas. Call your local Medical Assistance (Medicaid) office to find out more about their rules (phone numbers are in Section 6 of this chapter). Or call 1-800-MEDICARE (1-800-633-4227) 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 https://www.medicare.gov for more information.]

Medicare Coverage Gap Discount Program

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D members who have reached the coverage gap and are not receiving “Extra Help.” For brand name drugs, the 50% discount provided by manufacturers excludes any dispensing fee for costs in the gap. Members pay 30% of the negotiated price and a portion of the dispensing fee for brand name drugs.

If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your Part D Explanation of Benefits (EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and move you through the coverage gap. The amount paid by the plan (15%) does not count toward your out-of-pocket costs.

You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays 63% of the price for generic drugs and you pay the remaining 37% of the price. For generic drugs, the amount paid by the plan (63%) 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.

[Insert if the plan offers additional coverage in the gap: The Medicare Coverage Gap Discount Program is available nationwide. Because [insert 2019 plan name] offers additional gap coverage during the Coverage Gap Stage, your out-of-pocket costs will sometimes be lower than the costs described here. Please go to Chapter 4, Section 6 for more information about your coverage during the Coverage Gap Stage.]

[Insert if the plan does not have a coverage gap: The Medicare Coverage Gap Discount Program is available nationwide. Because [insert 2019 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 4, Section 5 for more information about your coverage during the Initial Coverage Stage.]

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 20% of the costs of brand drugs in the coverage gap. The 50% discount and the 20% paid by the plan are both 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.]

For information on eligibility criteria, covered drugs, or how to enroll in the program, please call [insert State-specific ADAP contact information].

What if you get “Extra Help” from Medicare to help pay your prescription drug costs? Can you get the discounts?

No. If you get “Extra Help,” you already get coverage for your prescription drug costs during the coverage gap.

What if you don’t get a discount, and you think you should have?

If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should review your next Part D Explanation of Benefits (Part D EOB) notice. If the discount doesn’t appear on your Part D Explanation of Benefits, you should contact us to make sure that your prescription records are correct and up-to-date. If we don’t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

State Pharmaceutical Assistance Programs

[Plans without an SPAP in their state(s), should delete this section.]

[Organizations offering plans in multiple states: Revise this section to include a list of SPAP names, phone numbers, and addresses for all states in your service area. Plans have the option of including a separate exhibit to list the SPAPs in all states or in all states in which the plan is filed and should make reference to that exhibit below.]

Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, medical condition, or disabilities. Each state has different rules to provide drug coverage to its members.

[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].

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) and days and hours of operation]
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] [Note: plans may add email addresses here.]
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	https://secure.rrb.gov/

SECTION 9 Do you have “group insurance” or other health insurance from an employer?

If you (or your spouse) get benefits from your (or your spouse’s) employer or retiree group as part of this plan, you may call the employer/union benefits administrator or Member Services if you have any questions. You can ask about your (or your spouse’s) employer or retiree health benefits, premiums, or the enrollment period. (Phone numbers for Member Services are printed on the back cover of this booklet.) You may also call 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan.

If you have other prescription drug coverage through your (or your spouse’s) employer or retiree group, please contact that group’s benefits administrator. The benefits administrator can help you determine how your current prescription drug coverage will work with our plan.

Chapter 3

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

Chapter 3. Using the plan’s coverage for your Part D prescription drugs

SECTION 1 Introduction 42

Section 1.1 This chapter describes your coverage for Part D drugs 42

Section 1.2 Basic rules for the plan’s Part D drug coverage 43

SECTION 2 Fill your prescription at a network pharmacy [insert if applicable: or through the plan’s mail-order service] 43

Section 2.1 To have your prescription covered, use a network pharmacy 43

Section 2.2 Finding network pharmacies 44

Section 2.3 Using the plan’s mail-order services 45

Section 2.4 How can you get a long-term supply of drugs? 47

Section 2.5 When can you use a pharmacy that is not in the plan’s network? 48

SECTION 3 Your drugs need to be on the plan’s “Drug List” 49

Section 3.1 The “Drug List” tells which Part D drugs are covered 49

Section 3.2 There are [insert number of tiers] “cost-sharing tiers” for drugs on the Drug List 50

Section 3.3 How can you find out if a specific drug is on the Drug List? 50

SECTION 4 There are restrictions on coverage for some drugs 51

Section 4.1 Why do some drugs have restrictions? 51

Section 4.2 What kinds of restrictions? 51

Section 4.3 Do any of these restrictions apply to your drugs? 52

SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered? 53

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 53

Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? 53

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 or defined standard coinsurance across all tiers) that does not allow for tiering exceptions: omit Section 5.3] 56

SECTION 6 What if your coverage changes for one of your drugs? 56

Section 6.1 The Drug List can change during the year 56

Section 6.2 What happens if coverage changes for a drug you are taking? 57

SECTION 7 What types of drugs are not covered by the plan? 58

Section 7.1 Types of drugs we do not cover 58

SECTION 8 Show your plan membership card when you fill a prescription 60

Section 8.1 Show your membership card 60

Section 8.2 What if you don’t have your membership card with you? 60

SECTION 9 Part D drug coverage in special situations 60

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare? 60

Section 9.2 What if you’re a resident in a long-term care (LTC) facility? 61

Section 9.3 What if you are taking drugs covered by Original Medicare? 61

Section 9.4 What if you have a Medigap (Medicare Supplement Insurance) policy with prescription drug coverage? 62

Section 9.5 What if you’re also getting drug coverage from an employer or retiree group plan? 62

Section 9.6 What if you are in Medicare-certified Hospice? 63

SECTION 10 Programs on drug safety and managing medications 63

Section 10.1 Programs to help members use drugs safely 63

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 64

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 sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Member Services and ask for the “LIS Rider.” (Phone numbers for Member Services are printed on the back cover of this booklet.)

SECTION 1 Introduction

Section 1.1 This chapter describes your coverage for Part D drugs

This chapter explains rules for using your coverage for Part D drugs. The next chapter tells what you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs).

In addition to your coverage for Part D drugs through our plan, Original Medicare (Medicare Part A and Part B) also covers some drugs:

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

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

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

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, dentist, or other prescriber) write your prescription.

• Your prescriber must either accept Medicare or file documentation with CMS showing that he or she is qualified to write prescriptions, or your Part D claim will be denied. You should ask your prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes time for your prescriber to submit the necessary paperwork to be processed.

• 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 cost-sharing. 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).

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. You can find out more about how your out-of-pocket costs could be different for different drugs by contacting us.] [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. If you are in an LTC facility, we must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies, which is typically the pharmacy that the LTC facility uses. If you have any difficulty accessing your Part D benefits in an LTC facility, 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).

Section 2.3 Using the plan’s mail-order services

[Omit section if the plan does not offer mail-order services.]

[Include the following information only if your mail-order service is limited to a subset of all formulary drugs, adapting terminology as needed: For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. [Insert if plan marks mail-order drugs in formulary: The drugs available through our plan’s mail-order service are marked as “mail-order” drugs in our Drug List.] [Insert if plan marks non-mail-order drugs in formulary: The drugs that are not available through the plan’s mail-order service are marked with an asterisk in our Drug List.]]

Our plan’s mail-order service [insert either: allows OR requires] you to order [insert either: at least a [XX]-day supply of the drug and no more than a [XX]-day supply OR up to a [XX]-day supply OR a [XX]-day supply].

[Plans that offer mail-order benefits with both preferred and standard cost-sharing may add language to describe both types of cost-sharing.]

To get [insert if applicable: order forms and] information about filling your prescriptions by mail [insert instructions].

Usually a mail-order pharmacy order will get to you in no more than [XX] days. [Insert plan’s process for members to get a prescription if the mail order is delayed.]

[Sponsors should provide the appropriate information below from the following options, based on i) whether the sponsor is operating under the exception for new prescriptions described in the December 12, 2013, HPMS memo; and ii) whether the sponsor offers an optional automatic refill program. Sponsors who provide automatic delivery through retail or other non-mail order means have the option to either add or replace the word “ship” with “deliver” as appropriate.]

[For new prescriptions received directly from health care providers, insert one of the following two options.]

[Option 1: Plan sponsors operating under the auto-ship policy as described in the 2014 Final Call Letter (all new prescriptions from provider offices must be verified with the beneficiary before filled), insert the following:

New prescriptions the pharmacy receives directly from your doctor’s office.
After the pharmacy receives a prescription from a health care provider, it will contact you to see if you want the medication filled immediately or at a later time. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if needed, allow you to stop or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.]

[Option 2: Plan Sponsors operating under the exception to the auto-ship policy, as described in the December 12, 2013, HPMS memo (new prescriptions received directly from provider offices can be filled without beneficiary verification when conditions are met), insert the following:

New prescriptions the pharmacy receives directly from your doctor’s office.
The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either:

• You used mail-order services with this plan in the past, or

• You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions now or at any time by [insert instructions].

If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.

If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact us by [insert instructions].

If you have never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. 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. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.

To opt out of automatic deliveries of new prescriptions received directly from your health care provider’s office, please contact us by [insert instructions].]

[For refill prescriptions, insert one of the following two options.]

[Option 1: Sponsors that do not offer a program that automatically processes refills, insert the following:

Refills on mail-order prescriptions. For refills, please contact your pharmacy [insert recommended number of days] days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.]

[Option 2: Sponsors that do offer a program that automatically processes refills, insert the following:

Refills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for an automatic refill program [optional: “called insert name of auto refill program”]. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto refill program, please contact your pharmacy [insert recommended number of days] days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.

To opt out of our program [optional: insert name of auto refill program instead of “our program”] that automatically prepares mail-order refills, please contact us by [insert instructions].]

[All plans offering mail-order services, insert the following:

So the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. [Insert instructions on how members should provide their communication preferences.]]

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 (also called an “extended supply”) of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) [Insert if applicable: You may order this supply through mail order (see Section 2.3) or you may go to a retail pharmacy]

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 long-term 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

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. [Insert if applicable: To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.] If you cannot 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.) You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to pay you back.)

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; and, for cancer, the National Comprehensive Cancer Network and Clinical Pharmacology or their successors.)

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:

Over-the-Counter Drugs

Our plan also covers certain over-the-counter drugs. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. For more information, call Member Services (phone numbers are printed on the back cover of this booklet).]

What is not on the Drug List?

The plan does not cover all prescription drugs.

• In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more about this, see Section 7.1 in this chapter).

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

Section 3.2 There are [insert number of tiers] “cost-sharing tiers” for drugs on the Drug List

[Plans that do not use drug tiers should omit this section.]

Every drug on the plan’s Drug List is in one of [insert number of tiers] cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug:

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

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

The amount you pay for drugs in each cost-sharing tier is shown in Chapter 4 (What you pay for your Part D prescription drugs).

Section 3.3 How can you find out if a specific drug is on the Drug List?

You have [insert number] ways to find out:

1. Check the most recent Drug List we [insert: sent you in the mail] OR [insert: provided electronically]. [Insert if applicable: (Please note: The Drug List we provide 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 provided Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Member Services to find out if we cover it.)]

2. Visit the plan’s website ([insert URL]). The Drug List on the website is always the most current.

3. Call Member Services to find out if a particular drug is on the plan’s Drug List or to ask for a copy of the list. (Phone numbers for Member Services are printed on the back cover of this booklet.)

4. [Plans may insert additional ways to find out if a drug is on the Drug List.]

SECTION 4 There are restrictions on coverage for some drugs

Section 4.1 Why do some drugs have restrictions?

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

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 higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost-sharing.

If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)

Please note that sometimes a drug may appear more than once in our drug list. This is because different restrictions or cost-sharing may apply based on factors such as the strength, amount, or form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet versus liquid).

Section 4.2 What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs.

[Plans should include only the forms of utilization management used by the plan.]

Restricting brand name drugs when a generic version is available

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

Getting plan approval in advance

For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.

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 by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

Section 4.3 Do any of these restrictions apply to your drugs?

The plan’s Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call Member Services (phone numbers are printed on the back cover of this booklet) or check our website ([insert URL]).

If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact Member Services to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)

SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered?

Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered

We hope that your drug coverage will work well for you. But it’s possible that there could be a prescription drug you are currently taking, or one that you and your provider think you should be taking that is not on our formulary or is on our formulary with restrictions. 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.

• 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. [Delete sentence if plan does not have step therapy] For example, 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 sentence 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.

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

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

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

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

Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way?

If your drug is not on the Drug List or is restricted, here are things you can do:

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

• You can change to another drug.

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

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

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 all current members will be transitioned in advance for the following year.] For those members who are new or 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 your membership in the plan if you were new and during the first [insert time period (must be at least 90 days)] of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of [insert supply limit (must be at least a 30-day supply)]. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of [insert supply limit (must be at least a 30-day supply)] of medication. The prescription must be filled at a network pharmacy.

• For those members who are new or 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 if you are new and during the first [insert time period (must be at least 90 days)] of the calendar year if you were in the plan last year. 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 [(must be at least a 91-day supply) and may be up to a 98-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 of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.

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

To ask for a temporary supply, call Member Services (phone numbers are printed on the back cover of this booklet).

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options.

You can change to another drug

Start by talking with your provider. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phone numbers for Member Services are printed on the back cover of this booklet.)

You can ask for an exception

You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.

[Plans may omit the following paragraph if they do not have an advance transition process for current members.] If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for next year. You can ask for an exception before next year, and we will give you an answer within 72 hours after we receive your request (or your prescriber’s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect.

If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? [Plans with a formulary structure (e.g., no tiers or defined standard coinsurance across all tiers) that does not allow for tiering exceptions: omit Section 5.3]

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

You can change to another drug

If your drug is in a cost-sharing tier you think is too high, start by talking with your provider. Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phone numbers for Member Services are printed on the back cover of this booklet.)

You can ask for an exception

You and your provider can ask the plan to make an exception in the cost-sharing tier for the drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule.

If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

[Insert if applicable: Drugs of our [insert name of specialty tier] are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs in this tier.]

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 changes to the Drug List. For example, the plan might:

• Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.

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

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

• Replace a brand name drug with a generic drug.

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

Section 6.2 What happens if coverage changes for a drug you are taking?

How will you find out if your drug’s coverage has been changed?

If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time.

Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. Your provider will also know about this change, and can work with you to find another drug for your condition.

Do changes to your drug coverage affect you right away?

If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan:

• [Plans that do not use tiers may omit] If we move your drug into a higher cost-sharing tier.

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

• 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.

  • 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.

  • Or you and your provider can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 7 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

• Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away.

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

SECTION 7 What types of drugs are not covered by the plan?

Section 7.1 Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” This means Medicare does not pay for these drugs.

If you get drugs that are excluded, you must pay for them yourself. We won’t pay for the drugs that are listed in this section [insert if applicable: (except for certain excluded drugs covered under our enhanced drug coverage)]. The only exception: If the requested drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid for or covered it because of your specific situation. (For information about appealing a decision we have made to not cover a drug, go to Chapter 7, Section 5.5 in this booklet.)

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.

  • 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, for cancer, the National Comprehensive Cancer Network and Clinical Pharmacology, or their successors. If the use is not supported by any of these reference books, then our plan cannot cover its “off-label use.”

Also, by law, these categories of drugs are not covered by Medicare drug plans [Insert if applicable: (Our plan covers certain drugs listed below through our enhanced drug coverage, for which you may be charged an additional premium. More information is provided below.)]:

• Non-prescription drugs (also called over-the-counter drugs)

• Drugs when used to promote fertility

• Drugs when used for the relief of cough or cold symptoms

• Drugs when used for cosmetic purposes or to promote hair growth

• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

• Drugs when used for the treatment of sexual or erectile dysfunction

• Drugs when used for treatment of anorexia, weight loss, or weight gain

• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

[Insert if applicable: We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage). [Insert details about the excluded drugs your plan does cover, including whether you place any limits on that coverage.] The amount you pay when you fill a prescription for these drugs does not count toward qualifying you for the Catastrophic Coverage Stage. (The Catastrophic Coverage Stage is described in Chapter 4, Section 7 of this booklet.)]

[Insert if plan offers coverage for any drugs excluded under Part D: In addition, if you are receiving “Extra Help” from Medicare to pay for your prescriptions, the “Extra Help” program will not pay for the drugs not normally covered. (Please refer to the plan’s Drug List or call Member Services for more information. Phone numbers for Member Services are printed on the back cover of this booklet.) However, if you have drug coverage through Medicaid, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.)]

[Insert if plan does not offer coverage for any drugs excluded under Part D: If you receive “Extra Help” paying for your drugs, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.)]

SECTION 8 Show your plan membership card when you fill a prescription

Section 8.1 Show your membership card

To fill your prescription, show your plan membership card at the network pharmacy you choose. When you show your plan membership card, the network pharmacy will automatically bill the plan for our share of your covered prescription drug cost. You will need to pay the pharmacy your share of the cost when you pick up your prescription.

Section 8.2 What if you don’t have your membership card with you?

If you don’t have your plan membership card with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information.

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

SECTION 9 Part D drug coverage in special situations

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare?

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

If you are admitted to a skilled nursing facility for a stay covered by Original Medicare, Medicare Part A will generally cover your prescription drugs during all or part of your stay. If you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage.

Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a Special Enrollment Period. During this time period, you can switch plans or change your coverage. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan and join a different Medicare plan.)

Section 9.2 What if you’re a resident in a long-term care (LTC) facility?

Usually, a long-term care facility (LTC) (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part of our network.

Check your Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of our network. If it isn’t, or if you need more information, please contact Member Services (phone numbers are printed on the back cover of this booklet).

What if you’re a resident in a long-term care (LTC) facility and become a new member of the plan?

If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a temporary supply of your drug during the first [insert time period (must be at least 90 days)] of your membership. The total supply will be for a maximum of [insert supply limit (must be at least a 91-day supply and may be up to a 98-day supply depending on the dispensing increment)], or less if your prescription is written for fewer days. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you have been a member of the plan for more than [insert time period (must be at least 90 days)] and need a drug that is not on our Drug List or if the plan has any restriction on the drug’s coverage, we will cover one [insert supply limit (must be at least a 31-day supply)] supply, or less if your prescription is written for fewer days.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do.

Section 9.3 What if you are taking drugs covered by Original Medicare?

Your enrollment in [insert 2019 plan name] doesn’t affect your coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it, even if you choose not to enroll in Part A or Part B.

Some drugs may be covered under Medicare Part B in some situations and through [insert 2019 plan name] in other situations. But drugs are never covered by both Part B and our plan at the same time. In general, your pharmacist or provider will determine whether to bill Medicare Part B or [insert 2019 plan name] for the drug.

Section 9.4 What if you have a Medigap (Medicare Supplement Insurance) policy with prescription drug coverage?

If you currently have a Medigap policy that includes coverage for prescription drugs, you must contact your Medigap issuer and tell them you have enrolled in our plan. If you decide to keep your current Medigap policy, your Medigap issuer will remove the prescription drug coverage portion of your Medigap policy and lower your premium.

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

Section 9.5 What if you’re also getting drug coverage from an employer or retiree group plan?

Do you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group? If so, please contact that group’s benefits administrator. He or she can help you determine how your current prescription drug coverage will work with our plan.

In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first.

Special note about ‘creditable coverage’:

Each year your employer or retiree group should send you a notice that tells if your prescription drug coverage for the next calendar year is “creditable” and the choices you have for drug coverage.

If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn’t get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from the employer or retiree group’s benefits administrator or the employer or union.

Section 9.6 What if you are in Medicare-certified Hospice?

Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare hospice and require an anti-nausea, laxative, pain medication, or antianxiety drug that is not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription.

In the event you either revoke your hospice election or are discharged from hospice, our plan should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this section that tell about the rules for getting drug coverage under Part D. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay.

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 complex health needs. For example, some members have several medical conditions, take different drugs at the same time, and have 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 get the most benefit from the drugs they take. Our [if applicable replace “Our” with “One”] program is called a Medication Therapy Management (MTM) program. Some members who take medications for different medical conditions may be able to get services through an MTM program. 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, and any problems or questions you have about your prescription and over-the-counter medications. 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 have 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, keep your medication list with you (for example, with your ID) in case 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).

Chapter 4

What you pay for your Part D prescription drugs

Chapter 4. What you pay for your Part D prescription drugs

SECTION 1 Introduction 69

Section 1.1 Use this chapter together with other materials that explain your drug coverage 69

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs 70

SECTION 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug 70

Section 2.1 What are the drug payment stages for [insert 2019 plan name] members? 70

SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in 72

Section 3.1 We send you a monthly report called the “Part D Explanation of Benefits” (the “Part D EOB”) 72

Section 3.2 Help us keep our information about your drug payments up to date 72

SECTION 4 During the Deductible Stage, you pay the full cost of your [insert drug tiers if applicable] drugs 73

Section 4.1 You stay in the Deductible Stage until you have paid $[insert deductible amount] for your [insert drug tiers if applicable] drugs 73

SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share 74

Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription 74

Section 5.2 A table that shows your costs for a one-month supply of a drug 75

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 76

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 77

Section 5.5 You stay in the Initial Coverage Stage until your [insert as applicable: total drug costs for the year reach $[insert 2019 initial coverage limit] OR out-of-pocket costs for the year reach $[insert 2019 out-of-pocket threshold]] 78

Section 5.6 How Medicare calculates your out-of-pocket costs for prescription drugs 79

SECTION 6 During the Coverage Gap Stage, [insert as appropriate: you receive a discount on brand name drugs and pay no more than 44% of the costs for generic drugs OR the plan provides some drug coverage] 82

Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $[insert 2019 out-of-pocket threshold] 82

Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs 83

SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs 85

Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year 85

SECTION 8 Additional benefits information 86

Section 8.1 Our plan offers additional benefits 86

SECTION 9 What you pay for vaccinations covered by Part D depends on how and where you get them 86

Section 9.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine 86

Section 9.2 You may want to call us at Member Services before you get a vaccination 88

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 sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Member Services and ask for the “LIS Rider.” (Phone numbers for Member Services are printed on the back cover of this booklet.)

SECTION 1 Introduction

Section 1.1 Use this chapter together with other materials that explain your drug coverage

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

To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs, as described in Chapter 5, Section 1.2. For out-of-pocket costs you may pay for your covered services, the amount you pay for a drug is called “cost-sharing” and there are three ways you may be asked to pay: deductibles, copayments, and coinsurance.

• The plan’s List of Covered Drugs (Formulary). To keep things simple, we call this the “Drug List.”

  • This Drug List tells which drugs are covered for you.

  • [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.

  • If you need a copy of the Drug List, call Member Services (phone numbers are printed on the back cover of this booklet). You can also find the Drug List on our website at [insert URL]. The Drug List on the website is always the most current.

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

• The plan’s Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list of pharmacies in the plan’s network. It also tells you which pharmacies in our network can give you a long-term supply of a drug (such as filling a prescription for a 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 2019 plan name] members?

As shown in the table below, there are “drug payment stages” for your prescription drug coverage under [insert 2019 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.]

Stage 1 Yearly Deductible Stage	Stage 2 Initial Coverage Stage	Stage 3 Coverage Gap Stage	Stage 4 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.] During this stage, you pay the full cost of your [insert if applicable: brand name OR [tier name(s)]] drugs. You stay in this stage until you have paid $[insert deductible amount] for your [insert if applicable: brand name OR [tier name(s)]] drugs ($[insert deductible amount] is the amount of your [insert if applicable: brand name OR [tier name(s)]] deductible). (Details are in Section 4 of this chapter.) [Plans with no deductible replace the text above with: Because there is no deductible for the plan, this payment stage does not apply to you.]	[Insert if plan has no deductible: You begin in this stage when you fill your first prescription of the year.] [Insert if plan has no deductible or a deductible that applies to all drugs: During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.] [Insert if plan has a deductible that applies to some drugs: During this stage, the plan pays its share of the cost of your [insert if applicable: generic OR [tier name(s)]] drugs and you pay your share of the cost. After you (or others on your behalf) have met your [insert if applicable: brand name OR [tier name(s)]] deductible, the plan 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 2019 initial coverage limit]. OR “out-of-pocket costs” (your payments) reach $[insert 2019 out-of-pocket threshold].] (Details are in Section 5 of this chapter.)	[Plans with no additional gap coverage insert: During this stage, you pay 35% of the price for brand name drugs (plus a portion of the dispensing fee) and 44% of the price for generic drugs.] [Plans with additional 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 44% of the costs, whichever is lower]. For brand name drugs, you pay 35% 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 2019 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 coverage gap replace the text above with: Because there is no coverage gap for the plan, this payment stage does not apply to you.]	During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2019). (Details are in Section 7 of this chapter.)

SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in

Section 3.1 We send you a monthly report called the “Part D Explanation of Benefits” (the “Part D EOB”)

Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of:

• We keep track of how much you have paid. This is called your “out-of-pocket” cost.

• We keep track of your “total drug costs.” This is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan.

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

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

• Totals for the year since January 1. This is called “year-to-date” information. It shows you the total drug costs and total payments for your drugs since the year began.

Section 3.2 Help us keep our information about your drug payments up to date

To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can help us keep your information correct and up to date:

• Show your membership card when you get a prescription filled. To make sure we know about the prescriptions you are filling and what you are paying, show your plan membership card every time you get a prescription filled.

• Make sure we have the information we need. There are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 5, Section 2 of this booklet.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs:

  • 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.

  • When you made a copayment for drugs that are provided under a drug manufacturer patient assistance program.

  • Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances.

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

• Check the written report we send you. When you receive a Part D Explanation of Benefits (an EOB) in the mail, please look it over to be sure the information is complete and correct. If you think something is missing from the report, or you have any questions, please call us at Member Services (phone numbers are printed on the back cover of this booklet). [Plans that allow members to manage this information on-line may describe that option here.] Be sure to keep these reports. They are an important record of your drug expenses.

SECTION 4 During the Deductible Stage, you pay the full cost of your [insert drug tiers if applicable] drugs

Section 4.1 You stay in the Deductible Stage until you have paid $[insert deductible amount] for your [insert drug tiers if applicable] drugs

[Plans with no deductible replace Section 4 title with: There is no deductible for [insert 2019 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 2019 plan name]. You begin in the Initial Coverage Stage when you fill your first prescription of the year. See Section 5 for information about your coverage in the Initial Coverage Stage.]

The Deductible Stage is the first payment stage for your drug coverage. [Plans with a deductible for all drug types/tiers, insert: This stage begins when you fill your first prescription in the year. When you are in this payment stage, you must pay the full cost of your drugs until you reach the plan’s deductible amount, which is $[insert deductible amount] for 2019.] [Plans with a deductible on only a subset of drugs, insert: You will pay a yearly deductible of $[insert deductible amount] on [insert applicable drug tiers] drugs. You must pay the full cost of your [insert applicable drug tiers] drugs until you reach the plan’s deductible amount. For all other drugs you will not have to pay any deductible and will start receiving coverage immediately.]

• Your “full cost” is usually lower than the normal full price of the drug, since our plan has negotiated lower costs for most drugs.

• The “deductible” is the amount you must pay for your Part D prescription drugs before the plan begins to pay its share.

Once you have paid $[insert deductible amount] for your [insert drug tiers if applicable] drugs, you leave the Deductible Stage and move on to the next drug payment stage, which is the Initial Coverage Stage.

SECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share

Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription

During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your [insert as applicable: copayment OR coinsurance amount OR copayment or coinsurance amount]). Your share of the cost will vary depending on the drug and where you fill your prescription.

The plan has [insert number of tiers] Cost-Sharing Tiers

[Plans that do not use drug tiers should omit this section.]

Every drug on the plan’s Drug List is in one of [insert number of tiers] cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug:

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

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

Your pharmacy choices

How much you pay for a drug depends on whether you get the drug from:

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

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

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

• A pharmacy that is not in the plan’s network

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

For more information about these pharmacy choices and filling your prescriptions, see Chapter 3 in this booklet and the plan’s Pharmacy Directory.

[Include if plan has network pharmacies that offer preferred cost-sharing. Generally, we will cover your prescriptions only if they are filled at one of our network pharmacies. Some of our network pharmacies also offer preferred cost-sharing. You may go to either network pharmacies that offer preferred cost-sharing or other network pharmacies that offer standard cost-sharing to receive your covered prescription drugs. Your costs may be less at pharmacies that offer preferred cost-sharing.]

Section 5.2 A table that shows your costs for a one-month supply of a drug

[Plans using only copayments or only coinsurance should edit this paragraph to reflect the plan’s cost-sharing.] During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance.

• “Copayment” means that you pay a fixed amount each time you fill a prescription.

• “Coinsurance” means that you pay a percent of the total cost of the drug each time you fill a prescription.

[Plans that do not use drug tiers, omit] As shown in the table below, the amount of the copayment or coinsurance depends on which tier your drug is in. Please note:

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

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

[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 cost-sharing 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:

Tier	Standard retail-cost-sharing (in-network) (up to a [insert number of days]-day supply)	Preferred retail cost-sharing (in-network) (up to a [insert number of days]-day supply)	Mail-order cost-sharing (up to a [insert number of days]-day supply)	Long-term care (LTC) cost-sharing (up to a [insert number of days]-day supply)	Out-of-network cost-sharing (Coverage is limited to certain situations; see Chapter 3 for details.) (up to a [insert number of days]-day supply)
Cost-Sharing Tier 1 ([insert description, e.g., “generic drugs”])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]
Cost-Sharing Tier 2 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]
Cost-Sharing Tier 3 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]
Cost-Sharing Tier 4 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]

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, the amount you pay for a prescription drug covers 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 your doctor prescribes less than a full month’s supply, you will not have to pay for the full month’s supply for certain drugs.

The amount you pay when you get less than a full month’s supply will depend on whether you are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat dollar amount).

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

  • [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.

Daily cost-sharing allows you to make sure a drug works for you before you have to pay for an entire month’s supply. You can also ask your doctor to prescribe, and your pharmacist to dispense, less than a full month’s supply of a drug or drugs, if this will help you better plan refill dates for different prescriptions so that you can take fewer trips to the pharmacy. The amount you pay will depend upon the days’ supply you receive.

Section 5.4 A table that shows your costs for a long-term [insert if applicable: up to a] [insert number of days]-day supply of a drug

[Plans that do not offer extended-day supplies delete Section 5.4.]

For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is [insert if applicable: up to] a [insert number of days]-day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 3, Section 2.4.)

The table below shows what you pay when you get a long-term [insert if applicable: up to a] [insert number of days]-day supply of a drug.

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

[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 cost-sharing cell: “Mail order is not available for drugs in [insert tier].”]

[Plans must include all of their tiers in the table. If plans do not offer extended-day supplies for certain tiers, the plan should use the following text in the cost-sharing cell: “A long-term supply is not available for drugs in [insert tier].”]

Your share of the cost when you get a long-term supply of a covered Part D prescription drug:

Tier	Standard retail cost-sharing (in-network) ([insert if applicable: up to a] [insert number of days]-day supply)	Preferred retail cost-sharing (in-network) ([insert if applicable: up to a] [insert number of days]-day supply)	Mail-order cost-sharing([insert if applicable: up to a] [insert number of days]-day supply)
Cost-Sharing Tier 1 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]
Cost-Sharing Tier 2 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]
Cost-Sharing Tier 3 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]
Cost-Sharing Tier 4 ([insert description])	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]	[Insert copay/ coinsurance]

Section 5.5 You stay in the Initial Coverage Stage until your [insert as applicable: total drug costs for the year reach $[insert 2019 initial coverage limit] OR out-of-pocket costs for the year reach $[insert 2019 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:

  • [Plans without a deductible, omit] The $[insert deductible amount] you paid when you were in the Deductible Stage.

  • 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 2019, 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 2019 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 2019 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 toward your [insert if plan has a coverage gap: initial coverage limit or total out-of-pocket costs.] [Insert only if plan pays for OTC drugs as part of its administrative costs: We also provide some over-the-counter medications exclusively for your use. These over-the-counter drugs are provided at no cost to you.] To find out which drugs our plan covers, refer to your formulary.]

The Explanation of Benefits (EOB) that we send to you will help you keep track of how much you and the plan, as well as any third parties, have spent on your behalf during the year. Many people do not reach the [insert as applicable: $[insert initial coverage limit] OR $[insert 2019 out-of-pocket threshold]] limit in a year.

We will let you know if you reach this [insert as applicable: $[insert initial coverage limit] OR $[insert 2019 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 with no 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 2019 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.

These payments are included in your out-of-pocket costs

When you add up your out-of-pocket costs, you can include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 3 of this booklet):

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

  • [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 an SPAP in their state delete next item] by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare’s “Extra Help” Program are also included.

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

Moving on to the Catastrophic Coverage Stage:

When you (or those paying on your behalf) have spent a total of $[insert 2019 out-of-pocket threshold] in out-of-pocket costs within the calendar year, you will move from the Initial Coverage Stage to the Catastrophic Coverage Stage.

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 brand or 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 government-funded health programs such as TRICARE and Veterans Affairs.

• Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Workers’ 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 2019 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.

• 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 44% 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 2019 out-of-pocket threshold]

[Plans with no coverage gap replace Section 6 title with: There is no coverage gap for [insert 2019 plan name].]

[Plans with no coverage gap replace Section 6.1 title with: You do not have a coverage gap for your Part D drugs.]

[Plans with no coverage gap replace text below with: There is no coverage gap for [insert 2019 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 35% of the negotiated price and a portion of the dispensing fee for brand name drugs. 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 move you through the coverage gap. 

You also receive some coverage for generic drugs. You pay no more than 44% of the cost for generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (56%) 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 44% of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2019, that amount is $[insert 2019 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 2019 out-of-pocket threshold], you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs

[Plans with a coverage gap: insert 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.

These payments are included in your out-of-pocket costs

When you add up your out-of-pocket costs, you can include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 3 of this booklet):

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

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

• The Initial Coverage Stage

• The Coverage Gap Stage

• Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan.

It matters who pays:

• If you make these payments yourself, they are included in your out-of-pocket costs.

• These payments are also included if they are made on your behalf by certain other individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, [plans without an SPAP in their state delete next item] by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare’s “Extra Help” Program are also included.

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

Moving on to the Catastrophic Coverage Stage:

When you (or those paying on your behalf) have spent a total of $[insert 2019 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.

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 brand or 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 government-funded health programs such as TRICARE and Veterans Affairs.

• Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Workers’ 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 2019 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.

• 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 2019 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:

  • – either – Coinsurance of 5% of the cost of the drug

• –or – $[Insert 2019 catastrophic cost-sharing amount for generics/preferred multisource drugs] for a generic drug or a drug that is treated like a generic and $[insert 2019 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.]

SECTION 9 What you pay for vaccinations covered by Part D depends on how and where you get them

Section 9.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of vaccinations:

• The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication.

• The second part of coverage is for the cost of giving you the vaccine. (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).

• Some vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s List of Covered Drugs (Formulary).

• Other vaccines are considered medical benefits. They are covered under Original Medicare.

2. Where you get the vaccine medication.

3. Who gives you the vaccine.

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 vaccine, you will have to pay the entire cost for both the vaccine medication and for getting the vaccine. 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 vaccine, 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 vaccine. [Insert if applicable: Remember you are responsible for all of the costs associated with vaccines (including their administration) during the [insert as applicable: Deductible Stage OR Coverage Gap Stage OR Deductible and Coverage Gap Stage] of your benefit.]

Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccine 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 vaccine.

• Our plan will pay the remainder of the costs.

Situation 2: You get the Part D vaccination at your doctor’s office.

• When you get the vaccination, you will pay for the entire cost of the vaccine and its administration.

• You can then ask our plan to pay our share of the cost by using the procedures that are described in Chapter 5 of this booklet (Asking us to pay our share of the costs for covered drugs).

• You will be reimbursed the amount you paid less your normal [insert as appropriate: coinsurance OR copayment] for the vaccine (including administration) [Insert the following only if an out-of-network differential is charged: less any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help,” we will reimburse you for this difference.)]

Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccine.

• 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 vaccine, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 5 of this booklet.

• You will be reimbursed the amount charged by the doctor for administering the vaccine [Insert the following only if an out-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.)]

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

Section 9.2 You may want to call us at Member Services before you get a vaccination

The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first at Member Services whenever you are planning to get a vaccination. (Phone numbers for Member Services are printed on the back cover of this booklet.)

• We can tell you about how your vaccination is covered by our plan and explain your share of the cost.

• We can tell you how to keep your own cost down by using providers and pharmacies in our network.

• If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost.

Chapter 5

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

Chapter 5. Asking us to pay our share of the costs for covered drugs

SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drugs 90

Section 1.1 If you pay our plan’s share of the cost of your covered drugs, you can ask us for payment 90

SECTION 2 How to ask us to pay you back 91

Section 2.1 How and where to send us your request for payment 91

SECTION 3 We will consider your request for payment and say yes or no 92

Section 3.1 We check to see whether we should cover the drug and how much we owe 92

Section 3.2 If we tell you that we will not pay for all or part of the drug, you can make an appeal 92

SECTION 4 Other situations in which you should save your receipts and send copies to us 93

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 93

SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drugs

Section 1.1 If you pay our plan’s share of the cost of your covered drugs, you can ask us for payment

Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you).

Here are examples of situations in which you may need to ask our plan to pay you back. All of these examples are types of coverage decisions (for more information about coverage decisions, go to Chapter 7 of this booklet).

1. When you use an out-of-network pharmacy to get a prescription filled

If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. (We cover prescriptions filled at out-of-network pharmacies only in a few special situations. Please go to Chapter 3, Section 2.5 to learn more.)

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

2. When you pay the full cost for a prescription because you don’t have your plan membership card with you

If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or look up your enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself.

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

3. When you pay the full cost for a prescription in other situations

You may pay the full cost of the prescription because you find that the drug is not covered for some reason.

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

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

4. If you are retroactively enrolled in our plan

Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.)

If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement.

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

[Plans should insert additional circumstances under which they will accept a paper claim from a member.]

All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 7 of this booklet (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has information about how to make an appeal.

SECTION 2 How to ask us to pay you back

Section 2.1 How and where to send us your request for payment

Send us your request for payment, along with your receipt documenting the payment you have made. It’s a good idea to make a copy of your receipts for your records.

[If the plan has developed a specific form for requesting payment, insert the following language: To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment.

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

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

Mail your request for payment together with any receipts to us at this address:

[Insert address]

[If the plan allows members to submit oral payment requests, insert the following language:

You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look for the section called [plans may edit section title as necessary] Where to send a request that asks us to pay for our share of the cost of a drug you have received.]

[Insert if applicable: You must submit your claim to us within [insert timeframe] of the date you received the service, item, or drug.]

Contact Member Services if you have any questions (phone numbers are printed on the back cover of this booklet). If you don’t know what you should have paid, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.

SECTION 3 We will consider your request for payment and say yes or no

Section 3.1 We check to see whether we should cover the drug and how much we owe

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

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

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

Section 3.2 If we tell you that we will not pay for all or part of the drug, you can make an appeal

If you think we have made a mistake in turning down your request for payment or you don’t agree with the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment.

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

SECTION 4 Other situations in which you should save your receipts and send copies to us

Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs

There are some situations when you should let us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we can calculate your out-of-pocket costs correctly. This may help you to qualify for the Catastrophic Coverage Stage more quickly.

Here are two situations when you should send us copies of receipts to let us know about payments you have made for your drugs:

1. When you buy the drug for a price that is lower than our price

[Plans with neither a coverage gap nor a deductible should delete this section.]

Sometimes when you are in the [insert if applicable: Deductible Stage OR Coverage Gap Stage OR Deductible Stage and Coverage Gap Stage] you can buy your drug at a network pharmacy for a price that is lower than our price.

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

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

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

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

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.

Chapter 6

Your rights and responsibilities

Chapter 6. Your rights and responsibilities

SECTION 1 Our plan must honor your rights as a member of the plan 97

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.) 97

Section 1.2 We must treat you with fairness and respect at all times 97

Section 1.3 We must ensure that you get timely access to your covered drugs 98

Section 1.4 We must protect the privacy of your personal health information 98

Section 1.5 We must give you information about the plan, its network of pharmacies, and your covered drugs 99

Section 1.6 We must support your right to make decisions about your care 100

Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made 101

Section 1.8 What can you do if you believe you are being treated unfairly or your rights are not being respected? 102

Section 1.9 How to get more information about your rights 102

SECTION 2 You have some responsibilities as a member of the plan 103

Section 2.1 What are your responsibilities? 103

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

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 interpreter services available to answer questions from disabled and 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 at no cost if you need it. We are required to give you information about the plan’s benefits in a format that is accessible and appropriate for you. 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) or contact [Name of Civil Rights Coordinator].

If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with [insert plan contact information]. You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights. Contact information is included in this Evidence of Coverage or with this mailing, or you may contact [plan customer service] for additional information.

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 at 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.

Section 1.3 We must ensure that you get timely access to your covered drugs

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

Section 1.4 We must protect the privacy of your personal health information

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

• Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.

• The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information?

• We make sure that unauthorized people don’t see or change your records.

• In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.

• There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.

  • For example, we are required to release health information to government agencies that are checking on quality of care.

  • 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 healthcare provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any purposes that are not routine.

If you have questions or concerns about the privacy of your personal health information, please call Member Services (phone numbers are printed on the back cover of this booklet).

[Note: Plans may insert custom privacy practices.]

Section 1.5 We must give you information about the plan, its network of pharmacies, and your covered drugs

[Plans may edit the section to reflect the types of alternate format materials available to plan members and/or language primarily spoken in the plan service area.]

As a member of [insert 2019 plan name], you have the right to get several kinds of information from us. (As explained above in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.)

If you want any of the following kinds of information, please call Member Services (phone numbers are printed on the back cover of this booklet):

• Information about our plan. This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare prescription drug plans.

• Information about our network pharmacies.

  • For example, you have the right to get information from us about the pharmacies in our network.

  • For a list of the pharmacies in the plan’s network, see the [insert name of pharmacy directory].

  • For more detailed information about our pharmacies, you can call Member Services (phone numbers are printed on the back cover of this booklet) or visit our website at [insert URL].

• Information about your coverage and the rules you must follow when using your coverage.

  • To get the details on your Part D prescription drug coverage, see Chapters 3 and 4 of this booklet plus the plan’s List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs.

  • 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.

  • If a Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the drug from an out-of-network pharmacy.

  • If you are not happy or if you disagree with a decision we make about what Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 7 of this booklet. It gives you the details about how to make an appeal if you want us to change our decision. (Chapter 7 also tells about how to make a complaint about quality of care, waiting times, and other concerns.)

  • If you want to ask our plan to pay our share of the cost for a Part D prescription drug, see Chapter 5 of this booklet.

Section 1.6 We must support your right to make decisions about your care

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

[Note: Plans that would like to provide members with state-specific information about advanced directives, including contact information for the appropriate state agency, may do so.]

Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:

• Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.

• Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.

If you want to use an “advance directive” to give your instructions, here is what to do:

• Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. [Insert if applicable: You can also contact Member Services to ask for the forms (phone numbers are printed on the back cover of this booklet).]

• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.

• Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.

• If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.

• If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.

What if your instructions are not followed?

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with [insert appropriate state-specific agency (such as the State Department of Health)]. [Plans also have the option to include a separate exhibit to list the state-specific agency in all states, or in all states in which the plan is filed, and then should revise the previous sentence to make reference to that exhibit.]

Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made

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

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

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

SECTION 2 You have some responsibilities as a member of the plan

Section 2.1 What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services (phone numbers are printed on the back cover of this booklet). We’re here to help.

• Get familiar with your covered drugs and the rules you must follow to get these covered drugs. Use this Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered drugs.

  • Chapters 3 and 4 give the details about your coverage for Part D prescription drugs.

• If you have any other prescription drug coverage in addition to our plan, you are required to tell us. Please call Member Services to let us know (phone numbers are printed on the back cover of this booklet).

  • We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered drugs from our plan. This is called “coordination of benefits” because it involves coordinating the drug benefits you get from our plan with any other drug benefits available to you. We’ll help you coordinate your benefits. (For more information about coordination of benefits, go to Chapter 1, Section 10.)

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

• Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.

  • 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.

  • Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.

  • 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.

• Pay what you owe. As a plan member, you are responsible for these payments:

  • [Insert if applicable: You must pay your plan premiums to continue being a member of our plan.]

  • For most of your drugs covered by the plan, you must pay your share of the cost when you get the drug. This will be a [insert as appropriate: copayment (a fixed amount) OR coinsurance (a percentage of the total cost)] Chapter 4 tells what you must pay for your Part D prescription drugs.

  • If you get any drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost.

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

[Plans that do not disenroll members for non-payment may modify this section as needed.]

• If you are required to pay a late enrollment penalty, you must pay the penalty to remain a member of the plan.

• 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).

  • If you move outside of our plan service area, you cannot remain a member of our plan. (Chapter 1 tells about our service area.) We can help you figure out whether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment Period when you can join any Medicare plan available in your new area. We can let you know if we have a plan in your new area.

  • 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.

  • 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.

  • Phone numbers and calling hours for Member Services are printed on the back cover of this booklet.

  • For more information on how to reach us, including our mailing address, please see Chapter 2.

Chapter 7

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

Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)

BACKGROUND 109

SECTION 1 Introduction 109

Section 1.1 What to do if you have a problem or concern 109

Section 1.2 What about the legal terms? 109

SECTION 2 You can get help from government organizations that are not connected with us 110

Section 2.1 Where to get more information and personalized assistance 110

SECTION 3 To deal with your problem, which process should you use? 110

Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? 110

COVERAGE DECISIONS AND APPEALS 111

SECTION 4 A guide to the basics of coverage decisions and appeals 111

Section 4.1 Asking for coverage decisions and making appeals: the big picture 111

Section 4.2 How to get help when you are asking for a coverage decision or making an appeal 112

SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal 113

Section 5.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug 113

Section 5.2 What is an exception? 115

Section 5.3 Important things to know about asking for exceptions 117

Section 5.4 Step-by-step: How to ask for a coverage decision, including an exception 117

Section 5.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan) 121

Section 5.6 Step-by-step: How to make a Level 2 Appeal 123

SECTION 6 Taking your appeal to Level 3 and beyond 125

Section 6.1 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals 125

MAKING COMPLAINTS 127

SECTION 7 How to make a complaint about quality of care, waiting times, customer service, or other concerns 127

Section 7.1 What kinds of problems are handled by the complaint process? 127

Section 7.2 The formal name for “making a complaint” is “filing a grievance” 129

Section 7.3 Step-by-step: Making a complaint 129

Section 7.4 You can also make complaints about quality of care to the Quality Improvement Organization 130

Section 7.5 You can also tell Medicare about your complaint 130

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

BACKGROUND

SECTION 1 Introduction

Section 1.1 What to do if you have a problem or concern

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

• For some types of problems, you need to use the process for coverage decisions and appeals.

• For other types of problems, you need to use the process for making complaints.

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you.

Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use.

Section 1.2 What about the legal terms?

There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand.

To keep things simple, this chapter explains the legal rules and procedures using simpler words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “coverage determination,” and “Independent Review Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible.

However, it can be helpful – and sometimes quite important – for you to know the correct legal terms for the situation you are in. Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations.

SECTION 2 You can get help from government organizations that are not connected with us

Section 2.1 Where to get more information and personalized assistance

Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step.

Get help from an independent government organization

We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do.

The services of SHIP counselors are free. [Plans providing SHIP contact information in an exhibit may revise the following sentence to direct members to it.] You will find phone numbers in Chapter 2, Section 3 of this booklet.

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:

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

• You can visit the Medicare website (https://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.

To figure out which part of this chapter will help with your specific problem or concern, START HERE

Is your problem or concern about your benefits or coverage?

(This includes problems about whether particular medical care or prescription drugs are covered or not, the way in which they are covered, and problems related to payment for medical care or prescription drugs.)

Yes. My problem is about benefits or coverage.

Go on to the next section of this chapter, Section 4, “A guide to the basics of coverage decisions and appeals.”

No. My problem is not about benefits or coverage.

Skip ahead to Section 7 at the end of this chapter: “How to make a complaint about quality of care, waiting times, customer service or other concerns.”

COVERAGE DECISIONS AND APPEALS

SECTION 4 A guide to the basics of coverage decisions and appeals

Section 4.1 Asking for coverage decisions and making appeals: the big picture

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

Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we 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. Under certain circumstances, which we discuss later, you can request an expedited or “fast coverage decision” or fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can ask for a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

Section 4.2 How to get help when you are asking for a coverage decision or making an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision:

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

• To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 of this chapter).

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

• You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

  • There may be someone who is already legally authorized to act as your representative under State law.

  • If you want a friend, relative, your doctor or other prescriber, or other person to be your representative, call Member Services (phone numbers are printed on the back cover of this booklet) and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at https://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf [plans may also insert: or on our website at [insert website or link to form]].) The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

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

SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal

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

Section 5.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug

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

• This section is about your Part D drugs only. To keep things simple, we generally say “drug” in the rest of this section, instead of repeating “covered outpatient prescription drug” or “Part D drug” every time.

• For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 3 (Using our plan’s coverage for your Part D prescription drugs) and Chapter 4 (What you pay for your Part D prescription drugs).

Part D coverage decisions and appeals

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

Legal Terms

An initial coverage decision about your Part D drugs is called a “coverage determination.”

Here are examples of coverage decisions you ask us to make about your Part D drugs:

• You ask us to make an exception, including:

  • Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary)

  • 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)

  • [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 drug on a higher cost-sharing tier

• 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.)

  • 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 5.2 of this chapter
Do you want us to cover a drug on our Drug List and you believe you meet any plan rules or restrictions (such as getting approval in advance) for the drug you need?	You can ask us for a coverage decision. Skip ahead to Section 5.4 of this chapter.
Do you want to ask us to pay you back for a drug you have already received and paid for?	You can ask us to pay you back. (This is a type of coverage decision.) Skip ahead to Section 5.4 of this chapter.
Have we already told you that we will not cover or pay for a drug in the way that you want it to be covered or paid for?	You can make an appeal. (This means you are asking us to reconsider.) Skip ahead to Section 5.5 of this chapter.

Section 5.2 What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are [insert as applicable: two OR three] examples of exceptions that you or your doctor or other prescriber can ask us to make:

1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). (We call it the “Drug List” for short.)

Legal Terms

Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a “formulary exception.”

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

2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 3).

Legal Terms

Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.”

• The extra rules and restrictions on coverage for certain drugs include:

  • [Omit if plan does not use generic substitution] Being required to use the generic version of a drug instead of the brand name drug.

  • [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.”)

  • [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.”)

  • [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.

• [Plans with a formulary structure (e.g., no tiers) that does not allow for tiering exceptions: omit this bullet] 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 our drug list contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to the alternative drug(s). This would lower your share of the cost for the drug.

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

Section 5.3 Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception.

Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception. [Plans with a formulary structure (e.g., no tiers) that does not allow for tiering exceptions: omit this statement] If you ask us for a tiering exception, we will generally not approve your request for an exception unless all the alternative drugs in the lower cost-sharing tier(s) won’t work as well for you.

We can say yes or no to your request

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

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

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

Section 5.4 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 a drug you have received.

• You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Section 4 of this chapter tells how you can give written permission to someone else to act as your representative. You can also have a lawyer act on your behalf.

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

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

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

• [Plans that allow members 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 after we receive your doctor’s statement.

• To get a fast coverage decision, you must meet two requirements:

  • 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.)

  • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

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

• If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether your health requires that we give you a fast coverage decision.

  • 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).

  • 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.

  • 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 of receiving the complaint. (The process for making a complaint is different from the process for coverage decisions and appeals. For more information about the process for making complaints, see Section 7 of this chapter.)

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

Deadlines for a “fast” coverage decision

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

  • 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.

  • 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.

  • Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to.

  • 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 –

  • 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.

• 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 5.5 Step-by-step: How to make a Level 1 Appeal
(how to ask for a review of a coverage decision made by our plan)

Legal Terms

An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.”

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

What to do

• To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.

  • 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 members 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.

  • 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.]

  • If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

If your health requires it, ask for a “fast appeal”

Legal Terms

A “fast appeal” is also called an “expedited redetermination.”

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

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

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

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

Deadlines for a “fast” appeal

• If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

  • 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.

  • 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 –

  • 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.

  • 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 5.6 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 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

• 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.

• If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization.

What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”)

If the Independent Review Organization “upholds the decision” you have the right to a Level 3 Appeal. However, to 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 drug 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 or attorney adjudicator. Section 6 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 6 Taking your appeal to Level 3 and beyond

Section 6.1 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned down.

If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level 3 Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels.

Level 3 Appeal A judge (called an Administrative Law Judge) or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer.

• 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 or attorney adjudicator within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision.

• If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over.

  • If you decide to accept this decision that turns down your appeal, the appeals process is over.

  • 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 or attorney adjudicator 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 Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of 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 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.

  • If you decide to accept this decision that turns down your appeal, the appeals process is over.

  • 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 Council says no to your appeal or denies your request to review the appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Level 5 Appeal A judge at the Federal District Court will review your appeal.

• This is the last step of the appeals process.

MAKING COMPLAINTS

SECTION 7 How to make a complaint about quality of care, waiting times, customer service, or other concerns

If your problem is about decisions related to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter.

Section 7.1 What kinds of problems are handled by the complaint process?

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

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

Complaint	Example
Quality of your medical care	Are you unhappy with the quality of the care you have received?
Respecting your privacy	Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?
Disrespect, poor customer service, or other negative behaviors	Has someone been rude or disrespectful to you? Are you unhappy with how our Member Services has treated you? Do you feel you are being encouraged to leave the plan?
Waiting times	Have you been kept waiting too long by pharmacists? Or by our Member Services or other staff at the plan? Examples include waiting too long on the phone or when getting a prescription.
Cleanliness	Are you unhappy with the cleanliness or condition of a pharmacy?
Information you get from us	Do you believe we have not given you a notice that we are required to give? Do you think written information we have given you is hard to understand?
Timeliness (These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals)	The process of asking for a coverage decision and making appeals is explained in sections 4-6 of this chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint process. However, if you have already asked us for a coverage decision or made an appeal, and you think that we are not responding quickly enough, you can also make a complaint about our slowness. Here are examples: If you have asked us to give you a “fast coverage decision” or a “fast appeal,” and we have said we will not, you can make a complaint. If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint. When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint. When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadline, you can make a complaint.

Section 7.2 The formal name for “making a complaint” is “filing a grievance”

Legal Terms

• What this section calls a “complaint” is also called a “grievance.”

• Another term for “making a complaint” is “filing a grievance.”

Another way to say “using the process for complaints” is “using the process for filing a grievance.”

Section 7.3 Step-by-step: Making a complaint

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

• Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. [Insert phone number, TTY, and days and hours of operation.]

• If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.

• [Insert description of the procedures (including time frames) and instructions about what members need to do if they want to use the process for making a complaint. Describe expedited grievance time frames for grievances about decisions to not conduct expedited organization/coverage determinations or reconsiderations/redeterminations.]

• Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.

• If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

Legal Terms

What this section calls a “fast complaint” is also called an “expedited grievance.”

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 day’s total) to answer your complaint. If we decide to take extra days, we will tell you in writing.

• If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Section 7.4 You can also make complaints about quality of care to the Quality Improvement Organization

You can make your complaint about the quality of care you received to us by using the step-by-step 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).

  • 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.

  • To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of this booklet. If you make a complaint to this organization, we will work with them to resolve your complaint.

• Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.

Section 7.5 You can also tell Medicare about your complaint

You can submit a complaint about [insert 2019 plan name] directly to Medicare. To submit a complaint to Medicare, go to https://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 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.

Chapter 8

Ending your membership in the plan

Chapter 8. Ending your membership in the plan

SECTION 1 Introduction 133

Section 1.1 This chapter focuses on ending your membership in our plan 133

SECTION 2 When can you end your membership in our plan? 133

Section 2.1 Usually, you can end your membership during the Annual Enrollment Period 133

Section 2.2 In certain situations, you can end your membership during a Special Enrollment Period 134

Section 2.3 Where can you get more information about when you can end your membership? 136

SECTION 3 How do you end your membership in our plan? 136

Section 3.1 Usually, you end your membership by enrolling in another plan 136

SECTION 4 Until your membership ends, you must keep getting your drugs through our plan 138

Section 4.1 Until your membership ends, you are still a member of our plan 138

SECTION 5 [Insert 2019 plan name] must end your membership in the plan in certain situations 138

Section 5.1 When must we end your membership in the plan? 138

Section 5.2 We cannot ask you to leave our plan for any reason related to your health 140

Section 5.3 You have the right to make a complaint if we end your membership in our plan 140

SECTION 1 Introduction

Section 1.1 This chapter focuses on ending your membership in our plan

Ending your membership in [insert 2019 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.

  • 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.

  • The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Section 3 tells you how to end your membership in each situation.

• There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 5 tells you about situations when we must end your membership.

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

SECTION 2 When can you end your membership in our plan?

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

Section 2.1 Usually, you can end your membership during the Annual Enrollment Period

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

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

• What type of plan can you switch to during the Annual Enrollment Period? 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:

  • Another Medicare prescription drug plan.

  • Original Medicare without a separate Medicare prescription drug plan.

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

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

    • If you enroll in most Medicare health plans, you will be disenrolled from [insert 2019 plan name] when your new plan’s coverage begins. However, if you choose a Private Fee-for-Service plan without Part D drug coverage, a Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll in that plan and keep [insert 2019 plan name] for your drug coverage. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or drop Medicare prescription drug coverage.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) [insert if applicable: See Chapter 1, Section 5 for more information about the late enrollment penalty.]

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

Section 2.2 In certain situations, you can end your membership during a Special Enrollment Period

In certain situations, members of [insert 2019 plan name] may be eligible to end their membership at other times of the year. This is known as a Special Enrollment Period.

• Who is eligible for a Special Enrollment Period? If any of the following situations apply to you, you are eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medicare, or visit the Medicare website (https://www.medicare.gov):

  • If you have moved out of your plan’s service area.

  • [Revise bullet to use state-specific name, if applicable] If you have Medicaid.

  • If you are eligible for “Extra Help” with paying for your Medicare prescriptions.

  • If we violate our contract with you.

  • If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital.

  • [Plans in states with PACE, insert: If you enroll in the Program of All-inclusive Care for the Elderly (PACE). [National or multi-state plans when there is variability in the availability of PACE insert: PACE is not available in all states. If you would like to know if PACE is available in your state, please contact Member Services (phone numbers are printed on the back cover of this booklet).]]

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

• What can you do? To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans:

  • Another Medicare prescription drug plan.

  • 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.

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

    • If you enroll in most Medicare health plans, you will automatically be disenrolled from [insert 2019 plan name] when your new plan’s coverage begins. However, if you choose a Private Fee-for-Service plan without Part D drug coverage, a Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll in that plan and keep [insert 2019 plan name] for your drug coverage. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or to drop Medicare prescription drug coverage.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may need to pay a Part D late enrollment penalty if you join a Medicare drug plan later. (“Creditable” coverage means the coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) [insert if applicable: See Chapter 1, Section 5 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 we receive your request to change your plan.

Section 2.3 Where can you get more information about when you can end your membership?

If you have any questions or would like more information on when you can end your membership:

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

• You can find the information in the Medicare & You 2019 Handbook.

  • Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up.

  • You can also download a copy from the Medicare website (https://www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below.

• You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

SECTION 3 How do you end your membership in our plan?

Section 3.1 Usually, you end your membership by enrolling in another plan

Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods (see Section 2 in this chapter for information about the enrollment periods). However, there are two situations in which you will need to end your membership in a different way:

• If you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan.

• If you join a Private Fee-for-Service plan without prescription drug coverage, a Medicare Medical Savings Account Plan, or a Medicare Cost Plan, enrollment in the new plan will not end your membership in our plan. In this case, you can enroll in that plan and keep [insert 2019 plan name] for your drug coverage. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or ask to be disenrolled from our plan.

If you are in one of these two situations and want to leave our plan, there are two ways you can ask to be disenrolled:

• You can make a request in writing to us. Contact Member Services if you need more information on how to do this (phone numbers are printed on the back cover of this booklet).

• --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a Part D 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 1, Section 5 for more information about the late enrollment penalty.

The table below explains how you should end your membership in our plan.

If you would like to switch from our plan to:	This is what you should do:
Another Medicare prescription drug plan.	Enroll in the new Medicare prescription drug plan between October 15 and December 7. You will automatically be disenrolled from [insert 2019 plan name] when your new plan’s coverage begins.
A Medicare health plan.	Enroll in the Medicare health plan by December 7. With most Medicare health plans, you will automatically be disenrolled from [insert 2019 plan name] when your new plan’s coverage begins. However, if you choose a Private Fee-For-Service plan without Part D drug coverage, a Medicare Medical Savings Account plan, or a Medicare Cost Plan, you can enroll in that new plan and keep [insert 2019 plan name] for your drug coverage. If you want to leave our plan, you must either enroll in another Medicare prescription drug plan or ask to be disenrolled. To ask to be disenrolled, you must send us a written request (contact Member Services (phone numbers are printed on the back cover of this booklet) if you need more information on how to do this) or contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY users should call 1-877-486-2048).
Original Medicare without a separate Medicare prescription drug plan. Note: If you disenroll from a Medicare prescription drug plan and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. See Chapter 1, Section 5 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 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.

SECTION 4 Until your membership ends, you must keep getting your drugs through our plan

Section 4.1 Until your membership ends, you are still a member of our plan

If you leave [insert 2019 plan name], it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.) During this time, you must continue to get your prescription drugs through our plan.

• You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy [insert if applicable: including through our mail-order pharmacy services.]

SECTION 5 [Insert 2019 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 2019 plan name] must end your membership in the plan if any of the following happen:

• If you no longer have Medicare Part A or Part B (or both).

• If you move out of our service area.

• If you are away from our service area for more than 12 months.

  • If you move or take a long trip, you need to call Member Services to find out if the place you are moving or traveling to is in our plan’s area. (Phone numbers for Member Services are printed on the back cover of this booklet.)

• If you become incarcerated (go to prison).

• If you are not a United States citizen or lawfully present in the United States.

• If you lie about or withhold information about other insurance you have that provides prescription drug coverage.

• [Omit if not applicable] If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

• [Omit bullet and sub-bullet if not applicable] If you continuously behave in a way that is disruptive and makes it difficult for us to provide care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

• [Omit bullet and sub-bullet if not applicable] If you let someone else use your membership card to get prescription drugs. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.)

  • 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].

  • 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

[Insert 2019 plan name] is not allowed to ask you to leave our plan for any reason related to your health.

What should you do if this happens?

If you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 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 file a grievance or can make a complaint about our decision to end your membership. You can also look in Chapter 7, Section 7 for information about how to make a complaint.

Chapter 9

Legal notices

Chapter 9. Legal notices

SECTION 1 Notice about governing law 143

SECTION 2 Notice about non-discrimination 143

SECTION 3 Notice about Medicare Secondary Payer subrogation rights 143

[Note: You may include other legal notices, such as a notice of member non-liability, a notice about third-party liability or a nondiscrimination notice under Section 1557 of the Affordable Care Act. 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 non-discrimination

[Plans may add language describing additional categories covered under state human rights laws.] We don’t discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location. All organizations that provide Medicare prescription drug plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason.

SECTION 3 Notice about Medicare Secondary Payer subrogation rights

We have the right and responsibility to collect for covered Medicare prescription drugs for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, [insert 2019 plan name], as a Medicare prescription drug plan sponsor, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any State laws.

[Note: You may include other legal notices, such as a notice of member non-liability, a notice about third-party liability or a nondiscrimination notice under Section 1557 of the Affordable Care Act. These notices may only be added if they conform to Medicare laws and regulations.]

Chapter 10

Definitions of important words

Chapter 10. Definitions of important words

[Plans should insert definitions as appropriate to the plan type described in the EOC. You may insert definitions not included in this model and exclude model definitions not applicable to your plan, or to your contractual obligations with CMS or enrolled Medicare beneficiaries.]

[If allowable revisions to terminology (e.g., changing “Member Services” to “Customer Service”) affect glossary terms, plans should re-label the term and alphabetize it within the glossary.]

Appeal – An appeal is something you do if you disagree with our decision to deny a request for coverage of prescription drugs or payment for drugs you already received. For example, you may ask for an appeal if we don’t pay for a drug you think you should be able to receive. Chapter 7 explains appeals, including the process involved in making an appeal.

Annual Enrollment Period – A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Annual Enrollment Period is from October 15 until December 7.

Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired.

Catastrophic Coverage Stage – The stage in the Part D Drug Benefit where you pay a low copayment or coinsurance for your drugs after you or other qualified parties on your behalf have spent $[insert 2019 out-of-pocket threshold] in covered drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers Medicare. Chapter 2 explains how to contact CMS.

Coinsurance – An amount you may be required to pay as your share of the cost for prescription drugs [insert if applicable: after you pay any deductibles]. Coinsurance is usually a percentage (for example, 20%).

Complaint – The formal name for “making a complaint” is “filing a grievance.” 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. See also “Grievance,” in this list of definitions.

Copayment (or “copay”) – An amount you may be required to pay as your share of the cost for a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a prescription drug.

Cost-sharing – Cost-sharing refers to amounts that a member has to pay when drugs are received. [Insert if plan has a premium: (This is in addition to the plan’s monthly premium.)] Cost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a drug, that a plan requires when a specific drug is 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 copayment.

[Delete if plan does not use tiers] Cost-Sharing Tier – Every drug on the list of covered drugs is in one of [insert number of tiers] cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug.

Coverage Determination – A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called “coverage decisions” in this booklet. Chapter 7 explains how to ask us for a coverage decision.

Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.

Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later.

Daily cost-sharing rate – A “daily cost-sharing rate” may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. This means you pay $1 for each day’s supply when you fill your prescription.

Deductible – The amount you must pay for prescriptions before our plan begins to pay.

Disenroll or Disenrollment – The process of ending your membership in our plan. Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).

Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and package the prescription.

Emergency – A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Evidence of Coverage (EOC) and Disclosure Information – This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan.

Exception – A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor’s formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Extra Help – A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.

Generic Drug – A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less.

Grievance – A type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes.

Income Related Monthly Adjustment Amount (IRMAA) – If your income is above a certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium. For example, individuals with income greater than $[insert amount] and married couples with income greater than $[insert amount] must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage premium amount. This additional amount is called the income-related monthly adjustment amount. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.

Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage.

Initial Coverage Stage – This is the stage before your [insert as applicable: total drug costs including amounts you have paid and what your plan has paid on your behalf OR out-of-pocket costs] for the year have reached [insert as applicable: [insert 2019 initial coverage limit] OR [insert 2019 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.

List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs.

Low Income Subsidy (LIS) – See “Extra Help.”

Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.

Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 3, Section 3 for more information about a medically accepted indication.

Medicare – The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare [insert only if there is a cost plan in your service area: a Medicare Cost Plan,] [insert only if there is a PACE plan in your state: a PACE plan,] or a Medicare Advantage Plan.

Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply).

[Insert cost plan definition only if you are a Medicare Cost Plan or there is one in your service area: Medicare Cost Plan – A Medicare Cost Plan is a plan operated by a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed contract under section 1876(h) of the Act.]

Medicare Coverage Gap Discount Program – A program that provides discounts on most covered Part D brand name drugs to Part D members 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.

Medicare Health Plan – A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE).

Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.

“Medigap” (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member (Member of our Plan, or “Plan Member”) – A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS).

Member Services – A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. See Chapter 2 for information about how to contact Member Services.

Network Pharmacy – A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them “network pharmacies” because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States.

Out-of-Network Pharmacy – A pharmacy that doesn’t have a contract with our plan to coordinate or provide covered drugs to members of our plan. As explained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply.

Out-of-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharing requirement to pay for a portion of drugs received is also referred to as the member’s “out-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 (LTC) services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high-quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan. [National or multi-state plans when there is variability in the availability of PACE insert: PACE is not available in all states. If you would like to know if PACE is available in your state, please contact Member Services (phone numbers are printed on the back cover of this booklet).]]

Part C – see “Medicare Advantage (MA) Plan.”

Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.)

Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.

[Include this definition only if Part D plan has pharmacies that offer preferred cost-sharing in addition to those offering standard cost-sharing:

Preferred Cost-sharing – Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs at certain network pharmacies.]

Part D 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, the late enrollment penalty rules do not apply to you. If you receive “Extra Help,” you do not pay a late enrollment penalty.

Premium – The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Prior Authorization – Approval in advance to get certain drugs that may or may not be on our formulary. [Plans may delete applicable sentences if it does not require prior authorization for any drugs.] Some drugs are covered only if your doctor or other network provider gets “prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.

Quality Improvement Organization (QIO) – A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.

Quantity Limits – A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Service Area – A geographic area where a prescription drug plan accepts members if it limits membership based on where people live. The plan may disenroll you if you permanently move out of the plan’s service area.

Special Enrollment Period – A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

[Include this definition only if Part D plan has pharmacies that offer preferred cost-sharing in addition to those offering standard cost-sharing:

Standard Cost-sharing – Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a network pharmacy.]

Step Therapy – A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed.

Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits.

[This is the back cover for the EOC. Plans may add a logo and/or photographs, as long as these elements do not make it difficult for members to find and read the plan contact information.]

[Insert 2019 plan name] Member Services

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	[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.]
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	[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]

PRA Disclosure Statement 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 0938-1051. If you have comments or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.