Form CMS-10316 Medicare Disenrollee Survey Prescriptopn Drug Plan

Attachment VII: PDP Survey

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Medicare Prescription Drug Plan Disenrollment Survey

As you answer the questions in this survey, please think only of your former
prescription drug plan whose name and contract number are printed in the box
below:

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OMB 0938-1113

Survey Instructions
This survey asks about you and the care you received from your former
prescription drug plan. The name of your former plan is printed on the cover of
this survey.
◆
◆

Answer each question based only on your experiences with your former plan.
Answer each question thinking about yourself.

As you complete the survey:
◆

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

oX
◆

Yes

Be sure to read all the answer choices given before marking your answer.

◆ Some questions have instructions that tell you to skip questions that may not apply

to you. When this happens you will see an arrow with a note that tells you what
question to answer next, like this: [If No, go to Question 3].
Please take the time to complete this survey. Your answers are very important
to us. Please return the survey with your answers in the enclosed postage-paid
envelope to CSS (the survey research organization helping CMS conduct this
survey).

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 09381113 (expires: TBD). The time required to complete this information collection is estimated to average 12 minutes
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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ATTENTION: Some questions have instructions that tell you to skip questions that
may not apply to you. Please check for a skip instruction after you answer each
question.

YOUR FORMER PRESCRIPTION DRUG PLAN
We are sending you this survey because we believe you recently switched or dropped
your Medicare prescription drug plan.
1. Our records show that you used to belong to the prescription drug plan whose
name is printed on the cover of this survey but that you no longer belong to that
plan. Is that right?

o Yes, I switched to a different Medicare prescription drug plan Go to Question 2
o I switched prescription drug plans but my former plan was not the plan printed on
the cover of this survey Go to Question 2

o No, I did not switch plans or drop my
Medicare prescription drug plan recently Stop. Do not complete the rest
of this survey. Please return the
survey in the enclosed envelope.
2. Did you have to switch plans or drop your former Medicare prescription drug
plan for any of the following reasons?
o I moved outside of the area where the plan was available
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.
o I was dropped by the plan
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.
o The plan was cancelled or discontinued in my area
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.
o The plan was changed or discontinued by the organization
that provides my insurance (such as a former employer or
a union)
Stop. Do not complete the rest of this survey. Please
return the survey in the enclosed envelope.

o None of the above

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Continue survey, go to Question 3

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GETTING INFORMATION OR
HELP FROM YOUR FORMER
PRESCRIPTION DRUG PLAN
As you answer the questions in this
survey, please think only of your former
prescription drug plan (whose name is
printed on the cover of this survey).

GETTING THE PRESCRIPTION
MEDICINES YOU NEEDED FROM
YOUR FORMER PRESCRIPTION
DRUG PLAN
5. How often was it easy to use your
former plan to get the medicines your
doctor prescribed?

o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to get

3. Did you ever try to get information
or help from your former plan’s
customer service?

o Yes
o No If No, go to Question 5
4. How often did your former plan’s
customer service give you the
information or help you needed?

o Never
o Sometimes
o Usually
o Always
o I did not try to get information or
help from my former plan’s
customer service

any prescription medicines

6. Did you ever use your former plan to
fill a prescription at a pharmacy?

o Yes
o No If No, go to Question 13
7. How often was it easy to use your
former plan to fill a prescription at a
pharmacy?

o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill a
prescription at a pharmacy
8. Did you ever use your former plan to
fill any prescriptions by mail?

o Yes
o No If No, go to Question 15
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9. How often was it easy to use your
former plan to fill prescriptions
by mail?

REASONS YOU LEFT YOUR
FORMER PRESCRIPTION
DRUG PLAN

o Never
o Sometimes
o Usually
o Always
o I did not use my former plan to fill

The next questions are about reasons
you may have had for switching or
dropping your former prescription drug
plan.
11. Did you leave your former plan
because you found out that someone
had signed you up for the plan
without your permission?

a prescription by mail
10. Using any number from 0 to 10,
where 0 is the worst prescription
drug plan possible and 10 is the
best prescription drug plan
possible, what number would you
use to rate your former plan?

o Yes
o No
12. Did you leave your former plan
because you were taken off the plan
by mistake?

o 0 Worst prescription drug
plan possible

o1
o2
o3
o4
o5
o6
o7
o8
o9
o 10 Best prescription drug plan possible

o Yes
o No
13. Did you leave your former plan
because the dollar amount you had
to pay each time you filled or refilled
a prescription went up?

o Yes
o No
o I did not have to pay for my
prescription medicines

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14. Some people have to pay their
prescription drug plan a monthly
fee (called a premium) out of
their own pocket for
prescription drug coverage.

18. Did you leave your former plan
because a change in your health
meant the plan no longer met your
needs?

o Yes
o No

Did you leave your former plan
because this monthly fee went up?

o Yes
o No
o I did not have to pay my former

19. Did you leave your former plan
because it turned out to be more
expensive than you expected?

o Yes
o No

plan a monthly fee out of my own
pocket

15. Prescription drug plans have a list
of the prescription medicines they
will cover. Did you leave your former
plan because they changed the list
of prescription medicines they
cover?

o Yes
o No
16. Did you leave your former plan
because you found a
prescription drug plan that
costs less?

o Yes
o No

20. Did you leave your former plan
because the plan refused to pay for a
medicine your doctor prescribed?

o Yes
o No
21. Did you leave your former plan
because you had problems getting
the medicines your doctor
prescribed?

o Yes
o No
22. Did you leave your former plan
because it was difficult to get brandname medicines?

17. Did you leave your former plan
because a change in your personal
finances meant you could no
longer afford the plan?

o Yes
o No
o I did not try to get brand-name

medicines through my former plan

o Yes
o No

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23. Did you leave your former plan
because you were frustrated by
the plan’s approval process for
medicines your doctor
prescribed?

o Yes
o No
24. Did you leave your former plan
because you did not know whom
to contact when you had a
problem filling or refilling a
prescription?

28. Did you leave your former plan
because their customer service staff
did not treat you with courtesy and
respect?

o Yes
o No
29. Every year Medicare evaluates all
prescription drug plans and gives
them a star rating.
Did you leave your former plan
because it got a low Medicare star
rating?

o Yes
o No

o Yes
o No

25. Did you leave your former plan
because it was hard to get
information from the plan—like
which prescription medicines were
covered or how much a specific
medicine would cost?

30. Did you leave your former plan
because you found another plan with
a higher Medicare star rating?

o Yes
o No

o Yes
o No
26. Did you leave your former plan
because you were unhappy with
how the plan handled a question
or complaint?

o Yes
o No

OTHER REASONS FOR LEAVING
YOUR FORMER PRESCRIPTION
DRUG PLAN
31. Did you leave your former plan
because a family member or friend
told you about a better plan?

o Yes
o No

27. Did you leave your former plan
because you could not get the
information or help you needed
from the plan?

o Yes
o No
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32. Did you leave your former plan
because you saw a commercial or
advertisement for a prescription
drug plan you thought you would
like better?

36. In general, how would you rate your
overall mental or emotional health?

o Excellent
o Very good
o Good
o Fair
o Poor

o Yes
o No
33. Did you leave your former plan
because you found another plan
that better met your prescription
needs?

37. In the past 12 months, how many
different prescription medicines did
you take?

o None
o 1 to 2 medicines
o 3 to 5 medicines
o 6 or more medicines

o Yes
o No
34. Did you leave your former plan
because you take very few
prescription medicines and
don’t need a prescription drug
plan?

38. In the past 12 months, have you seen
a doctor or other health provider 3 or
more times for the same condition or
problem?

o Yes
o No

o Yes
o No If No, go to Question 45
ABOUT YOU

39. Is this a condition or problem that
has lasted for at least 3 months?

o Yes
o No

35. In general, how would you rate
your overall health?

o Excellent
o Very good
o Good
o Fair
o Poor

40. Do you now need or take any
medicine prescribed by a doctor for
any condition?

o Yes
o No If No, go to Question 47

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

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

o Yes, Hispanic or Latino
o No, not Hispanic or Latino

o Yes
o No
42. Has a doctor ever told you that you
had any of the following conditions?
a. A heart attack
b. Angina or
coronary heart
disease

45. What is your race? Please mark one
or more.

o White
o Black or African-American
o Asian
o Native Hawaiian or other Pacific

o Yes o No
o Yes o No

Islander

c. High blood
pressure or
hypertension

o Yes o No

d. Cancer, other
than skin
cancer

o Yes o No

e. Emphysema,
asthma or
COPD (chronic
obstructive
pulmonary
disease)

o Yes o No

f. Any kid of
diabetes or high
blood sugar

o Yes o No

43. What is the highest grade or level
of school that you have completed?

o 8th grade or less
o Some high school, but did not

o American Indian or Alaska Native
46. What language do you mainly speak
at home?

o Chinese
o English
o Russian
o Spanish
o Vietnamese
o Some other language (please print)
47. Did someone help you complete
this survey?

o Yes
o No If No, go to Question 54
48. How did that person help
you? Please mark one or
more.

o Read the questions to me
o Wrote down the answers I gave
o Answered the questions for me
o Translated the questions into my

graduate
o High school graduate or GED
o Some college or 2-year degree
o 4-year college graduate
o More than 4-year college degree
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o
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language
Helped in some other way (please
print)

49. May we contact you again if we
have questions about your
survey responses or if we have
other questions about the health
care services that you received?

o Yes
o No

THANK YOU FOR COMPLETING THIS SURVEY
Please return your completed survey in the postage paid envelope to:
MEDICARE SATISFACTION SURVEY
PO BOX 3416
HOPKINS, MN 55343-9740

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