Form CMS-R-264 Prescription Drug Plan survey

Centers for Medicare & Medicaid Services
c/o Survey Processing
[INSERT VENDOR ADDRESS]

Dear FNAME LNAME:
The Centers for Medicare & Medicaid Services (CMS) is asking for feedback from
people in Medicare health and drug plans. We’d greatly appreciate your time to tell
us about your Medicare plan. Your input will improve Medicare services and help
others like you choose a drug plan.
Please take a few minutes to tell us about your experiences. Medicare uses this
information to improve plan quality and to rate and share information on all plans. Plan
ratings are publicly available at medicare.gov/plan-compare and in the “Medicare &
You” handbook.
The survey takes about 10 minutes. Participation is voluntary, and your information is
kept private by law.
For questions about this survey, please call the survey organization working with
Medicare toll-free at 1-XXX-XXX-XXXX, Monday - Friday from XX am - XX pm [INSERT
TIME ZONE].
Thank you for your help with this important project.
Sincerely,

Amy Larrick Chavez-Valdez
Director, Medicare Drug Benefit and C & D Data Group
Nota: Si le gustaría recibir una copia de la encuesta en español, por favor llame gratis
al 1-XXX-XXX-XXXX de lunes a viernes entre XX am y XX pm de [INSERT TIME
ZONE].

Medicare Experience Survey
MEDICARE SURVEY INSTRUCTIONS
This survey asks about you and the health care you received in the last six months.
Answer each question thinking about yourself and the times you got health care in
person, by phone or by video call. 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 [Survey Vendor].
If you changed your Medicare plan for 2021, answer the questions thinking about your
experiences in the last 6 months of 2020.
• Answer all the questions by putting an “X” in the box to the left of your answer, like
this:
•

•
•

Yes

Be sure to read all the answer choices given before marking your answer.
You are sometimes told not to answer some questions in this survey. 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]. See the example below:

EXAMPLE
1. Do you wear a hearing aid now?
Yes
No If No, Go to Question 3
2. How long have you been wearing a hearing aid?
Less than one year
1 to 3 years
More than 3 years
I don’t wear a hearing aid
3. In the last 6 months, did you have any headaches?
Yes
No
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. This applies to both mandatory and voluntary collections of
information. The valid OMB control number for this information collection is 0938-0732 (expires TBD). The time
required to complete this information collection is estimated to average 10 minutes, 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 C1-25-05,
Baltimore, Maryland 21244-1850.

1.

5.

Our records show that in 2020 your
prescriptions were covered by the
Medicare prescription drug plan
named on the back page.
Is that right?

Yes
No If No, Go to Question 7

Yes If Yes, Go to Question 3
No
2.

3.

In the last 6 months, how often
was it easy to use your
prescription drug plan to fill a
prescription at your local
pharmacy?
Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to fill a prescription
at my local pharmacy in the
last 6 months

In the last 6 months, did anyone
from a doctor’s office, pharmacy
or your prescription drug plan
contact you:
a. To make sure you
filled or refilled a
prescription?
b. To make sure you
were taking medicine
as directed?

4.

6.

Please write below the name of
the Medicare prescription drug
plan you had in 2020 and complete
the rest of the survey based on the
experiences you had with that
plan. (Please print)
___________________________

Yes

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

No

7.

In the last 6 months, did you ever
use your prescription drug plan to
fill a prescription by mail?
Yes
No If No, Go to Question 9
I am not sure if my drug plan
offers prescriptions by mail
Go to Question 9

In the last 6 months, how often
was it easy to use your
prescription drug plan to get the
medicines your doctor prescribed?
Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to get any medicines
in the last 6 months

1

8.

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

About You
10. In general, how would you rate
your overall health?

Never
Sometimes
Usually
Always
I did not use my prescription
drug plan to fill a prescription
by mail in the last 6 months
I am not sure if my drug plan
offers prescriptions by mail
9.

Excellent
Very good
Good
Fair
Poor
11. In general, how would you rate
your overall mental or emotional
health?
Excellent
Very good
Good
Fair
Poor

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

12. In the last 6 months, did you spend
one or more nights in a hospital?

0 - Worst prescription drug
plan possible
1
2
3
4
5
6
7
8
9
10 - Best prescription drug plan
possible

Yes
No
13. In the last 6 months, did you delay
or not fill a prescription because
you felt you could not afford it?
Yes
No
My doctor did not prescribe
any medicines for me in the
last 6 months
14. In the last 6 months, did you
receive any mail order medicines
that you did not request?
Yes
No
Don’t know

2

15. Has a doctor ever told you that
you had any of the following
conditions?
Yes
a. A heart attack?
b. Angina or coronary
heart disease?
c. Hypertension
or high blood
pressure?
d. Cancer, other than
skin cancer?
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary disease)?
f. Any kind of diabetes
or high blood
sugar?

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

No

8th grade or less
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
20. Are you of Hispanic or Latino origin
or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
21. What is your race? Please mark
one or more.

16. Do you have serious difficulty
walking or climbing stairs?

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

Yes
No
17. Do you have difficulty dressing or
bathing?

22. How many people live in your
household now, including
yourself?

Yes
No
18. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such
as visiting a doctor’s office or
shopping?

1 person
2 to 3 people
4 or more people
23.

Yes
No

Do you ever use the internet at
home?
Yes
No

3

24.

26. How did that person help you?
Please mark one or more.

May the Medicare Program follow
up with you to learn more about
your health care, or to invite you
to a group discussion or interview
on topics related to health care?

Read the questions to me
Wrote down the answers I
gave
Answered the questions for me
Translated the questions into
my language
Helped in some other way

Yes
No
25. Did someone help you complete
this survey?
Yes
No  Thank you. Please
return the completed
survey in the postagepaid envelope.

Thank you.
Please return the completed survey in the postage-paid envelope.
[SURVEY VENDOR RETURN ADDRESS FOR MAIL PROCESSING]
Contract Name: ________________
[OPTIONAL]
You may also know your plan by one of the following:

4