[Cost
plan models]
[2019
ANOC model]
[Insert 2019 plan name] ([insert plan type]) offered by [insert cost plan name]
[Optional:
insert beneficiary name]
[Optional:
insert beneficiary address]
You are currently enrolled as a member of [insert 2018 plan name]. Next year, there will be some changes to the plan’s costs and benefits. This booklet tells about the changes.
If you wish to enroll in a Medicare Advantage health plan or Medicare prescription drug plan, you have from October 15 until December 7 to make changes to your Medicare coverage for next year. If you decide other cost plan coverage better meets your needs, you can switch cost plans anytime the cost plan is accepting members. You may also change to Original Medicare. For more information see Section 4.2 of this document.
What to do now
ASK: Which changes apply to you
Check the changes to our benefits and costs to see if they affect you.
It’s important to review your coverage now to make sure it will meet your needs next year.
Do the changes affect the services you use?
Look in Sections [insert section number] and [insert section number] for information about benefit and cost changes for our plan.
[Plans that offer Part D, insert as applicable:
Check the changes in the booklet to our prescription drug coverage to see if they affect you.
Will your drugs be covered?
Are your drugs in a different tier, with different cost sharing?
Do any of your drugs have new restrictions, such as needing approval from us before you fill your prescription?
Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy?
Review the 2019 Drug List and look in Section [insert section number] for information about changes to our drug coverage.]
Check to see if your doctors and other providers will be in our network next year.
Are your doctors in our network?
What about the hospitals or other providers you use?
Look in Section [insert section number] for information about our Provider Directory.
Think about your overall health care costs.
How much will you spend out-of-pocket for the services and prescription drugs you use regularly?
How much will you spend on your premium and deductibles?
How do your total plan costs compare to other Medicare coverage options?
Think about whether you are happy with our plan.
COMPARE: Learn about other plan choices
Check coverage and costs of plans in your area.
Use the personalized search feature on the Medicare Plan Finder at https://www.medicare.gov website. Click “Find health & drug plans.”
Review the list in the back of your Medicare & You handbook.
Look in Section [edit section number as needed] 4.2 to learn more about your choices.
Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.
CHOOSE: Decide whether you want to change your plan
If you want to keep [insert plan name], you don’t need to do anything. You will stay in [insert plan name].
To change to a Medicare Advantage health plan or Medicare prescription drug plan, you can switch plans between October 15 and December 7.
ENROLL: To change to a Medicare Advantage health plan or Medicare prescription drug plan, join a plan between October 15 and December 7, 2018
If you don’t join another plan by December 7, 2018, you will stay in [insert 2018 plan name]. [If the plan is being crosswalked, replace previous sentence with: If you don’t join another plan by December 7, 2018, you will be enrolled in [insert 2019 plan name].
If you join another plan by December 7, 2018, your new coverage will start on January 1, 2019.
Additional Resources
[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.]
About [insert 2019 plan name]
[Insert Federal contracting statement.]
When this booklet says “we,” “us,” or “our,” it means [insert cost plan name]. When it says “plan” or “our plan,” it means [insert 2019 plan name].
[Insert
as applicable: [insert Material ID] CMS
Approved [MMDDYYYY]
OR [insert Material ID] File
& Use [MMDDYYYY]]
The table below compares the 2018 costs and 2019 costs for [insert 2019 plan name] in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the [insert as applicable: attached OR enclosed] Evidence of Coverage to see if other benefit or cost changes affect you.
If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the 2018 Medicare amounts and must insert: “These are 2018 cost sharing amounts and may change for 2019. [insert plan name] will provide updated rates as soon as they are released.” Member cost sharing amounts may not be left blank.
Cost |
2018 (this year) |
2019 (next year) |
Monthly plan premium* [Plans that offer Part D insert: Your premium may be higher or lower than this amount.] See [edit section number as needed] Section 2.1 for details. |
[Insert 2018 premium amount] |
[Insert 2019 premium amount] |
[Plans with no deductible may delete this row.] Deductible |
[Insert 2018 deductible amount] |
[Insert 2019 deductible amount] |
[Plans not offering MOOP may delete this row.] Maximum out-of-pocket amount This is the most you will pay out-of-pocket for your covered [insert if applicable: Part A and Part B] services. (See [edit section number as needed] Section 2.2 for details.) |
[Insert 2018 MOOP amount] |
[Insert 2019 MOOP amount] |
Doctor office visits |
Primary care visits: [insert 2018 cost-sharing for PCPs] per visit Specialist visits: [insert 2018 cost-sharing for specialists] per visit |
Primary care visits: [insert 2019 cost-sharing for PCPs] per visit Specialist visits: [insert 2019 cost-sharing for specialists] per visit |
Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day. |
[Insert 2018 cost-sharing] |
[Insert 2019 cost-sharing] |
[Plans that do not offer Part D delete.] Part D prescription drug coverage (See [edit section number as needed] Section 2.6 for details.) |
Deductible: [Insert 2018 deductible amount] [Copayment/Coinsurance as applicable] during the Initial Coverage Stage:
|
Deductible: [Insert 2019 deductible amount] [Copayment/Coinsurance as applicable] during the Initial Coverage Stage:
|
Annual
Notice of Changes
for 2019
Table of Contents
[Update table below after completing edits.]
Summary of Important Costs for 2019 1
SECTION 1 We Are Changing the Plan’s Name 4
SECTION 1 Unless You Choose Another Plan, You Will Be Automatically Enrolled in [insert 2019 plan name] in 2019 4
SECTION 2 Changes to Benefits and Costs for Next Year 5
Section 2.1 – Changes to the Monthly Premium 5
Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount 5
Section 2.3 – Changes to the Provider Network 6
Section 2.4 – Changes to the Pharmacy Network 7
Section 2.5 – Changes to Benefits and Costs for Medical Services 8
Section 2.6 – Changes to Part D Prescription Drug Coverage 9
SECTION 3 Administrative Changes 16
SECTION 4 Deciding Which Plan to Choose 16
Section 4.1 – If you want to stay in [insert 2019 plan name] 16
Section 4.2 – If you want to change plans 16
SECTION 5 Deadline for Changing Plans 17
SECTION 6 Programs That Offer Free Counseling about Medicare 18
SECTION 7 Programs That Help Pay for Prescription Drugs 18
SECTION 8 Questions? 19
Section 8.1 – Getting Help from [insert 2019 plan name] 19
Section 8.2 – Getting Help from Medicare 20
[If Section 1 does not apply, plans should omit it and renumber remaining sections as needed.]
[Plans that are changing the plan name, as approved by CMS, include Section 1, using the section title above and the following text:
On January 1, 2019, our plan name will change from [insert 2018 plan name] to [insert 2019 plan name].
[Insert language to inform members if they will receive new ID cards and how, as well as if the name change will impact any other beneficiary communication.]]
[If the beneficiary is being enrolled into another plan due to a consolidation, include Section 1, using the section title above and the text below. It is additionally expected that, as applicable throughout the ANOC, every plan/sponsor that cross walks a member from a non-renewed plan to a consolidated renewal plan will compare benefits and costs, including cost-sharing for drug tiers, from that member’s previous plan to the consolidated plan.]
On January 1, 2019, [insert cost plan name] will be combining [insert 2018 plan name] with one of our plans, [insert 2019 plan name].
If you do nothing to change your Medicare coverage by December 31, 2018, we will automatically enroll you in our [insert 2019 plan name]. You have choices about how to get your Medicare coverage. If you want to change to a different cost plan you may do so anytime the cost plan is accepting members. If you want to change to a Medicare Advantage plan or change your Part D prescription drug coverage, you must do so between October 15 and December 7, 2018. If you want to change to Original Medicare you may do so at any time. If you are eligible for Extra Help, you may be able to change plans during other times.
The information in this document tells you about the differences between your current benefits in [insert 2018 plan name] and the benefits you will have on January 1, 2019 as a member of [insert 2019 plan name].
[Plans may add a row to this table to display changes in premiums for optional supplemental benefits.]
[Plans that include a Part B premium reduction benefit may insert a row to describe the change in the benefit.]
Cost |
2018 (this year) |
2019 (next year) |
Monthly premium [Plans that include a Part B premium reduction benefit may modify this row to describe the change in the benefit. If there are no changes from year to year, plans may indicate in the column that there is no change for the upcoming benefit year.] (You must also continue to pay your Medicare Part B premium.) |
[Insert 2018 premium amount] |
[Insert 2019 premium amount] |
Your monthly plan premium will be more if you are required to pay a lifetime Part D late enrollment penalty for going without other drug coverage that is at least as good as Medicare drug coverage (also referred to as “creditable coverage”) for 63 days or more.
If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage.
Your monthly premium will be less if you are receiving “Extra Help” with your prescription drug costs.
[Plans that include the costs of supplemental benefits (e.g., POS benefits) in the MOOP limit may revise this information as needed.]
[Plans not offering MOOP: delete this section and renumber remaining sections as needed.]
To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket” during the year. This limit is called the “maximum out-of-pocket amount.” Once you reach this amount, you generally pay nothing for covered [insert if applicable: Part A and Part B] services for the rest of the year.
Cost |
2018 (this year) |
2019 (next year) |
Maximum out-of-pocket amount Your costs for covered medical services (such as copays [insert if plan has a deductible: and deductibles]) count toward your maximum out-of-pocket amount. [Plans with no premium and/or no Part D coverage may modify or delete the following sentence as needed.] Your plan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount. [If there are no changes from year to year, plans may indicate in the column that there is no change for the upcoming benefit year.] |
[Insert 2018 MOOP amount]
|
[Insert 2019 MOOP amount] Once you have paid [insert 2019 MOOP amount] out-of-pocket for covered [insert if applicable: Part A and Part B] services, you will pay nothing for your covered [insert if applicable: Part A and Part B] services for the rest of the calendar year. |
[Insert applicable section: For a plan that has changes in its provider network] There are changes to our network of providers for next year. [Insert if applicable: We included a copy of our Provider Directory in the envelope with this booklet.] An updated Provider Directory is located on our website at [insert URL]. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. Please review the 2019 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
OR
[For a plan that will have a higher than normal number of providers either leaving and/or joining its network] Our network has changed more than usual for 2019. [Insert if applicable: We included a copy of our Provider Directory in the envelope with this booklet.] An updated Provider Directory is located on our website at [insert URL]. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. We strongly suggest that you review our current Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are still in our network.
It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan but if your doctor or specialist does leave your plan you have certain rights and protections summarized below:
Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists.
We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.
We will assist you in selecting a new qualified provider to continue managing your health care needs.
If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.
If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed you have the right to file an appeal of our decision.
If you find out your doctor or specialist is leaving your plan please contact us so we can assist you in finding a new provider and managing your care.
[Plans that do not offer Part D delete Section 2.4.]
Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. [Insert if applicable: Our network includes pharmacies with preferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharing offered by other network pharmacies for some drugs.]
[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.
[If there are no changes in benefits or in cost-sharing, revise heading to “There are no changes to your benefits or amounts you pay for medical services” and replace the rest of this section with: Our benefits and what you pay for these covered medical services will be exactly the same in 2019 as they are in 2018.]
We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2019 Evidence of Coverage.
[The table must include: (1) all new benefits that will be added or 2018 benefits that will end for 2019, including any new optional supplemental benefits (plans must indicate these optional supplemental benefits are available for an extra premium); (2) new limitations or restrictions on Part C benefits for CY 2019; and (3) all changes in cost-sharing for 2019 for covered medical services, including any changes to service category out-of-pocket maximums and cost-sharing for optional supplemental benefits (plans must indicate these optional supplemental benefits are available for an extra premium).]
If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the 2018 Medicare amounts and must insert: “These are 2018 cost sharing amounts and may change for 2019. [insert plan name] will provide updated rates as soon as they are released.” Member cost sharing amounts may not be left blank.
Cost |
2018 (this year) |
2019 (next year) |
[Insert benefit name] |
[For benefits that were not covered in 2018 insert: [insert benefit name] is not covered.] [For
benefits with a copayment insert: [For
benefits with a coinsurance insert: [insert language as needed to accurately describe the benefit, e.g., “for up to one visit per year”].] |
[For benefits that were not covered in 2019 insert: [insert benefit name] is not covered.] [For
benefits with a copayment insert: [For
benefits with a coinsurance insert: [insert language as needed to accurately describe the benefit, e.g., “for up to one visit per year”].] |
[Insert benefit name] |
[Insert 2018 cost/coverage, using format described above.] |
[Insert 2019 cost/coverage, using format described above.] |
[Plans that do not offer Part D delete Section 2.6 below.]
Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is [insert: in this envelope] OR [insert: provided electronically]. [If including an abridged formulary, add the following language: The Drug List we [insert: included in this envelope] OR [insert: provided electronically] includes many – but not all – of the drugs that we will cover next year. If you don’t see your drug on this list, it might still be covered. You can get the complete Drug List by calling Member Services (see the back cover) or visiting our website ([insert URL]).]
[Plans with no changes to covered drugs, tier assignment, or restrictions may replace the rest of this section with: We have not made any changes to our Drug List for next year. The drugs included on our Drug List will be the same in 2019 as in 2018. However, we are allowed to make changes to the Drug List from time to time throughout the year, with approval from Medicare or if a drug has been withdrawn from the market by either the FDA or a product manufacturer.]
We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions.
If you are affected by a change in drug coverage, you can:
Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. [Plans may omit the following sentence if they do not have an advance transition process for current members.] We encourage current members to ask for an exception before next year.
To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Member Services.
Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Member Services to ask for a list of covered drugs that treat the same medical condition.
[Plans may omit this if all current members will be transitioned in advance for the following year.] In some situations, we are required to cover a temporary supply of a non-formulary drug in the first 90 days of the plan year or the first 90 days of membership to avoid a gap in therapy. [Plans changing the LTC supply (for instance, from a minimum of 90 days to a month’s supply, should insert the following: For 2019, members in long term care (LTC) facilities will now receive a temporary supply that is the same amount of temporary days supply provided in all other cases: [insert supply limit (must be at least the number of days in the plan’s one month)] of medication rather than the amount provided in 2018 ([insert 2018 LTC maximum supply limit) of medication]). (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
[Plans may include additional information about processes for transitioning current members to formulary drugs when your formulary changes relative to the previous plan year.]
[Include language to explain whether current formulary exceptions will still be covered next year or a new one needs to be submitted.]
Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are allowed by Medicare rules.
[Plan sponsors that otherwise meet all requirements and want the option to immediately replace brand name drugs with their new generic equivalents should insert the following: Starting in 2019, we may immediately remove a brand name drug on our Drug List if, at the same time, we replace it with a new generic drug on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. This means if you are taking the brand name drug that is being replaced by the new generic (or the tier or restriction on the brand name drug changes), you will no longer always get notice of the change 60 days before we make it or get a 60-day refill of your brand name drug at a network pharmacy. If you are taking the brand name drug, you will still get information on the specific change we made, but it may arrive after the change is made.
Also, starting in 2019, before we make other changes during the year to our Drug List that require us to provide you with advance notice if you are taking a drug, we will provide you with notice 30, rather than 60, days before we make the change. Or we will give you a [insert supply limit (must be at least the number of days in the plan’s one month)] day, rather than a 60 day, refill of your brand name drug at a network pharmacy.]
[Plan sponsors that will not be using the option to make immediate generic substitutions should insert the following:
Starting in 2019, before we make changes during the year to our Drug List that require us to provide you with advance notice when you are taking a drug, we will provide you with notice of those changes 30, rather than 60, days before they take place. Or we will give you a [insert supply limit (must be at least the number of days in the plan’s one month)] day, rather than a 60 day, refill of your brand name drug at a network pharmacy. We will provide this notice before, for instance, replacing a brand name drug on the Drug List with a generic drug or making changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare.]
[All plan sponsors should include the remainder of this section.]
When we make these changes to the Drug List during the year, you can still work with your doctor (or other prescriber) and ask us to make an exception to cover the drug. We will also continue to update our online Drug List as scheduled and provide other required information to reflect drug changes. (To learn more about the changes we may make to the Drug List, see Chapter 5, Section 6 of the Evidence of Coverage.)
[Plans that enroll partial dual eligible beneficiaries should delete the following paragraph for QDWI beneficiaries.] Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information about costs for Part D prescription drugs [insert as applicable: may OR does] not apply to you. [If not applicable, omit information about the LIS Rider.] We [insert as appropriate: have included OR sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug costs. If you receive “Extra Help” and [if plan sends LIS Rider with ANOC, insert: didn’t receive this insert with this packet,] [if plan sends LIS Rider separately from the ANOC, insert: haven’t received this insert by [insert date],] please call Member Services and ask for the “LIS Rider.” Phone numbers for Member Services are in Section [edit section number as needed] 8.1 of this booklet.
There are four “drug payment stages.” How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.)
The information below shows the changes for next year to the first two stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the [insert as applicable: attached OR enclosed] Evidence of Coverage.)
Changes to the Deductible Stage
Stage |
2018 (this year) |
2019 (next year) |
Stage 1: Yearly Deductible Stage During this stage, you pay the full cost of your [insert as applicable: Part D OR brand name OR [tier name(s)]] drugs until you have reached the yearly deductible. [Plans with no deductible, omit text above.] |
The deductible is $[insert 2018 deductible]. [Plans with no deductible replace the text above with: Because we have no deductible, this payment stage does not apply to you.] [Plans with tiers excluded from the deductible in 2018 and/or 2019 insert the following:] During this stage, you pay [insert cost-sharing amount that a beneficiary would pay in a tier(s) that is exempted from the deductible] cost-sharing for drugs on [insert name of tier(s) excluded from the deductible] and the full cost of drugs on [insert name of tier(s) where copayments apply] until you have reached the yearly deductible. |
The deductible is $[insert 2019 deductible]. [Plans with no deductible replace the text above with: Because we have no deductible, this payment stage does not apply to you.] [Plans with tiers excluded from the deductible in 2018 and/or 2019 insert the following:] During this stage, you pay [insert cost-sharing amount that a beneficiary would pay in a tier(s) that is exempted from the deductible] cost-sharing for drugs on [insert name of tier(s) excluded from the deductible] and the full cost of drugs on [insert name of tier(s) where copayments apply] until you have reached the yearly deductible. |
Changes to Your Cost-sharing in the Initial Coverage Stage
[Plans that are changing the cost-sharing from coinsurance to copayment or vice versa from 2018 to 2019 insert, “For drugs on [insert name of tier(s)], your cost-sharing in the initial coverage stage is changing from [insert whichever is appropriate “copayment to coinsurance” <or> “coinsurance to copayment.”] Please see the following chart for the changes from 2018 to 2019.”]
To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage.
[Plans must list all drug tiers in the table below and show costs for a one-month supply filled at a network retail pharmacy. Plans that have pharmacies that provide preferred cost-sharing must provide information on both standard and preferred cost-sharing using the second alternate chart. Plans without drug tiers may revise the table as appropriate.]
Stage |
2018 (this year) |
2019 (next year) |
Stage 2: Initial Coverage Stage [Plans with no deductible delete the first sentence.] Once you pay the yearly deductible, you move to the Initial Coverage Stage. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. [Plans that are changing the cost-sharing from a copayment to coinsurance or vice versa from 2018 to 2019 insert for each applicable tier: “For 2018 you paid [insert as appropriate “a $[xx] copayment” <or> “[xx]% coinsurance”] for drugs on [insert tier name]. For 2019 you will pay [insert as appropriate “a $[xx] copayment” <or> “[xx]% coinsurance”] for drugs on this tier.”] |
[Insert name of Tier 1]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Insert name of Tier 2]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Repeat for all tiers] |
[Insert name of Tier 1]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Insert name of Tier 2]: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost.] [Repeat for all tiers] |
Stage 2: Initial Coverage Stage (continued) The costs in this row are for a one-month ([insert number of days in a one-month supply]-day) supply when you fill your prescription at a network pharmacy that provides standard cost-sharing. [Plans that are changing the number of days in their one-month supply from 2018 to 2019 insert “The number of days in a one-month supply has changed from 2018 to 2019 as noted in the chart.”] For information about the costs [insert as applicable: for a long-term supply, at a network pharmacy that offers preferred cost-sharing, or for mail-order prescriptions], look in Chapter 6, Section 5 of your Evidence of Coverage. [Insert if applicable: We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.] |
Once [insert as applicable: your total drug costs have reached $[insert 2018 Initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2018 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).] |
Once [insert as applicable: your total drug costs have reached $[insert 2019 Initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2019 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).] |
[Plans with pharmacies that offer standard and preferred cost-sharing may replace the chart above with the one below to provide both cost-sharing rates.]
Stage |
2018 (this year) |
2019 (next year) |
Stage 2: Initial Coverage Stage [Plans with no deductible delete the first sentence.] Once you pay the yearly deductible, you move to the Initial Coverage Stage. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. [Plans that are changing the cost-sharing from a copayment to coinsurance or vice versa from 2018 to 2019 insert for each applicable tier: “For 2018 you paid [insert as appropriate “a $[xx] copayment” <or> “[xx]% coinsurance”] for drugs on this tier. For 2019 you will pay [insert as appropriate “a $[xx] copayment” <or> “[xx]% coinsurance”] for drugs on this tier.”] |
Your cost for a one-month [Plans that are changing the number of days in their one-month supply from 2018 to 2019 insert “([xx]-day)” rather than “one-month”] supply at a network pharmacy: [Insert name of Tier 1]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Insert name of Tier 2]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Repeat for all tiers] |
Your cost for a one-month [Plans that are changing the number of days in their one-month supply from 2018 to 2019 insert “([xx]-day)” rather than “one-month”] supply at a network pharmacy: [Insert name of Tier 1]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Insert name of Tier 2]: Standard cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. Preferred cost-sharing: You pay [insert as applicable: $[xx] per prescription OR [xx]% of the total cost]. [Repeat for all tiers] |
Stage 2: Initial Coverage Stage (continued) The costs in this row are for a one-month ([insert number of days in a one-month supply]-day) supply when you fill your prescription at a network pharmacy. [Plans that are changing the number of days in their one-month supply from 2018 to 2019 insert “The number of days in a one-month supply has changed from 2018 to 2019 as noted in the chart.”] For information about the costs [insert as applicable: for a long-term supply or for mail-order prescriptions], look in Chapter 6, Section 5 of your Evidence of Coverage. [Insert if applicable: We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.] |
______________ Once [insert as applicable: your total drug costs have reached $[insert 2018 initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2018 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).] |
______________ Once [insert as applicable: your total drug costs have reached $[insert 2019 initial coverage limit], you will move to the next stage (the Coverage Gap Stage). OR you have paid $[insert 2019 out-of-pocket threshold] out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage).] |
Changes to the Coverage Gap and Catastrophic Coverage Stages
The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage Stage – are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. [Sponsors that are changing the cost-sharing from coinsurance to copayment or vice versa from 2018 to 2019 insert the following sentence. If many changes are being made, it may be repeated as necessary. For [insert coverage stage involved] Coverage Stage, for drugs on Tiers] [xx] [insert tiers], your cost-sharing is changing from [insert whichever is appropriate “a copayment to coinsurance” <or> “coinsurance to a copayment.”] For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage.
[This section is optional. Plans with administrative changes that impact members (e.g., a change in options for paying the monthly premium, changes in prior authorization requirements, change in contract or PBP number) may insert this section and include an introductory sentence that explains the general nature of the administrative changes. Plans that choose to omit this section should renumber the remaining sections as needed.]
Process |
2018 (this year) |
2019 (next year) |
[Insert a description of the administrative process/item that is changing] |
[Insert 2018 administrative description] |
[Insert 2019 administrative description] |
[Insert a description of the administrative process/item that is changing] |
[Insert 2018 administrative description] |
[Insert 2019 administrative description] |
To stay in our plan you don’t need to do anything. If you do not sign up for a different cost plan or change to Original Medicare by December 31, you will automatically stay enrolled as a member of our plan for 2019.
We hope to keep you as a member next year but if you want to change for 2019 follow these steps:
Step 1: Learn about and compare your choices
You can join a different Medicare health plan,
-- OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan, if you don’t already have one.
To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2019, call your State Health Insurance Assistance Program (see Section [edit section number as needed] 6), or call Medicare (see Section [edit section number as needed] 8.2).
You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to https://www.medicare.gov and click “Find health & drug plans.” Here, you can find information about costs, coverage, and quality ratings for Medicare plans.
[Plans may choose to insert if applicable: As a reminder, [insert MAO name] offers other [insert as applicable: Medicare health plans AND/OR Medicare prescription drug plans. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts.]]
Step 2: Change your coverage
To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from [insert 2019 plan name].
To add a Medicare prescription drug plan or change to a different drug plan, enroll in the new drug plan. You will continue to receive your medical benefits from [insert 2019 plan name].
To change to Original Medicare with a prescription drug plan, you must enroll in the new drug plan and ask to be disenrolled from [insert 2019 plan name]. Enrolling in the new drug plan will not automatically disenroll you from [insert 2019 plan name]. To disenroll from [insert 2019 plan name] you must either:
Send us a written request to disenroll. Contact Member Services if you need more information on how to do this (phone numbers are in Section [edit section number as needed] 8.1 of this booklet).
– or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.
To change to Original Medicare without a prescription drug plan, you must either:
Send us a written request to disenroll. Contact Member Services if you need more information on how to do this (phone numbers are in Section [edit section number as needed] 8.1 of this booklet).
– or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.
If you want to change to a different type of plan, like a Medicare Advantage plan, or make a change to your prescription drug coverage for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2019.
If you want to change to a different cost plan, you can do so anytime the plan is accepting members. The new plan will let you know when the change will take effect.
If you want to disenroll from our plan and have Original Medicare for next year, you can make the change up to December 31. The change will take effect on January 1, 2019.
Are there other times of the year to make a change?
In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get “Extra Help” paying for their drugs, and those who move out of the service area may be allowed to make a change at other times of the year. For more information, see [insert as applicable: Chapter 8 OR Chapter 10], Section 2.1 of the Evidence of Coverage.
[Organizations offering plans in multiple states: Revise this section to use the generic name (“State Health Insurance Assistance Program”) when necessary, and include a list of names, phone numbers, and addresses for all SHIPs in your service area.]
The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In [insert state], the SHIP is called [insert state-specific SHIP name].
[Insert state-specific SHIP name] is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. [Insert state-specific SHIP name] counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call [insert state-specific SHIP name] at [insert SHIP phone number]. [Plans may insert the following: You can learn more about [insert state-specific SHIP name] by visiting their website ([insert SHIP website]).]
You may qualify for help paying for prescription drugs. [Plans in states without SPAPs delete the next sentence.] Below we list different kinds of help:
“Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if you qualify, call:
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 and 7 pm, Monday through Friday. TTY users should call, 1-800-325-0778 (applications); or
Your State Medicaid Office (applications).
[Plans without an SPAP in their state(s), should delete this bullet.] [Organizations offering plans in multiple states: Revise this bullet to use the generic name (“State Pharmaceutical Assistance Program”) when necessary, and include a list of names for all SPAPs in your service area.] Help from your state’s pharmaceutical assistance program. [Insert state name] has a program called [insert state-specific SPAP name] that helps people pay for prescription drugs based on their financial need, age, or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section [edit section number as needed] 6 of this booklet).
[Plans with an ADAP in their state(s) that do NOT provide Insurance Assistance should delete this bullet.] [Plans with no Part D drug cost-sharing should delete this section.] Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance through the [insert State-specific ADAP name and information]. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call [insert State-specific ADAP contact information].
Questions? We’re here to help. Please call Member Services at [insert member services phone number]. (TTY only, call [insert TTY number].) We are available for phone calls [insert days and hours of operation]. [Insert if applicable: Calls to these numbers are free.]
Read your 2019 Evidence of Coverage (it has details about next year's benefits and costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2019. For details, look in the 2019 Evidence of Coverage for [insert 2019 plan name]. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is included in this envelope.
Visit our Website
You can also visit our website at [insert URL]. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) [plans that do not offer Part D, omit] and our list of covered drugs (Formulary/Drug List).
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227)
You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Visit the Medicare Website
You can visit the Medicare website (https://www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to https://www.medicare.gov and click on “Find health & drug plans.”)
Read Medicare & You 2019
You can read Medicare & You 2019 Handbook. Every year in
the fall, this booklet is mailed to people with Medicare. It has a
summary of Medicare benefits, rights and protections, and answers to
the most frequently asked questions about Medicare. If you don’t
have a copy of this booklet, you can get it at the Medicare website
(https://www.medicare.gov)
or by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call
1-877-486-2048.
OMB Approval 0938-1051 (Pending OMB Approval)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2019 Cost Plan Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Templates |
| Subject | 2019 Cost Plan Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Templates |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |