CY2024_1_HMO_MAPD_ISNP_CSNP_EOC_30 day PRA CLEAN

Medicare Advantage and Prescription Drug Program: Final Marketing Provisions CFR 422.111(a)(3) and 423.128(a)(3) (CMS-10260)

CY2024_1_HMO_MAPD_ISNP_CSNP_EOC_30 day PRA CLEAN

OMB: 0938-1051

Document [pdf]

Download: pdf | pdf

[2024 EOC model]

January 1 – December 31, 2024

Evidence of Coverage:
Your Medicare Health Benefits and Services and Prescription Drug Coverage
as a Member of [insert 2024 plan name] [insert plan type]
[Optional: insert member name]
[Optional: insert member address]
This document gives you the details about your Medicare health care and prescription drug
coverage from January 1 – December 31, 2024. This is an important legal document. Please
keep it in a safe place.
For questions about this document, please contact Member Services at [insert phone
number] for additional information. (TTY users should call [insert TTY number]). Hours
are [insert days and hours of operation]. This call is free.
This plan, [insert 2024 plan name], is offered by [insert MAO name] [insert DBA names in
parentheses, as applicable, after listing required MAO names throughout this document]. (When
this Evidence of Coverage says “we,” “us,” or “our,” it means [insert MAO name] [insert DBA
names in parentheses, as applicable, after listing required MAO names]. When it says “plan” or
“our plan,” it means [insert 2024 plan name].)
[Plans that meet the 5% alternative language threshold insert: This document is available for
free in [insert languages that meet the 5% threshold]. [Plans must insert language about
availability of alternate formats (e.g., braille, large print, audio) as applicable.]
[Remove terms as needed to reflect plan benefits] Benefits, premiums, deductibles, and/or
copayments/coinsurance may change on January 1, 2025.
[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. We will
notify affected enrollees about changes at least 30 days in advance.
This document explains your benefits and rights. Use this document to understand about:
• Your plan premium and cost sharing;
• Your medical and prescription drug benefits;
• How to file a complaint if you are not satisfied with a service or treatment;
• How to contact us if you need further assistance; and,
• Other protections required by Medicare law.
[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID]]
OMB Approval 0938-1051 (Expires: February 29, 2024)

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

2024 Evidence of Coverage
Table of Contents
CHAPTER 1: Getting started as a member................................................................. 5
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7

Introduction ........................................................................................................6
What makes you eligible to be a plan member? ................................................8
Important membership materials you will receive...........................................10
Your monthly costs for [insert 2024 plan name] ............................................12
More information about your monthly premium .............................................16
Keeping your plan membership record up to date ...........................................19
How other insurance works with our plan .......................................................20

CHAPTER 2: Important phone numbers and resources ........................................ 22
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7
SECTION 8
SECTION 9

[Insert 2024 plan name] contacts (how to contact us, including how to
reach Member Services) ..................................................................................23
Medicare (how to get help and information directly from the Federal
Medicare program)...........................................................................................26
State Health Insurance Assistance Program (free help, information,
and answers to your questions about Medicare) ..............................................27
Quality Improvement Organization .................................................................29
Social Security .................................................................................................30
Medicaid ..........................................................................................................31
Information about programs to help people pay for their prescription
drugs .................................................................................................................32
How to contact the Railroad Retirement Board ...............................................34
Do you have group insurance or other health insurance from an
employer? .........................................................................................................35

CHAPTER 3: Using the plan for your medical services .......................................... 36
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6

Things to know about getting your medical care as a member of our
plan...................................................................................................................37
Use providers in the plan’s network to get your medical care.........................39
How to get services when you have an emergency or urgent need for
care or during a disaster ...................................................................................41
What if you are billed directly for the full cost of your services? ...................44
How are your medical services covered when you are in a clinical
research study? .................................................................................................44
Rules for getting care in a religious non-medical health care institution ........46

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

SECTION 7

Rules for ownership of durable medical equipment ........................................47

CHAPTER 4: Medical Benefits Chart (what is covered and what you pay) ............ 50
SECTION 1
SECTION 2
SECTION 3

Understanding your out-of-pocket costs for covered services.........................51
Use the Medical Benefits Chart to find out what is covered and how
much you will pay............................................................................................54
What services are not covered by the plan? .....................................................97

CHAPTER 5: Using the plan’s coverage for Part D prescription drugs ............... 100
SECTION 1
SECTION 2

Introduction ....................................................................................................101
Fill your prescription at a network pharmacy [insert if applicable: or
through the plan’s mail-order service] ...........................................................101
SECTION 3 Your drugs need to be on the plan’s “Drug List” ..........................................106
SECTION 4 There are restrictions on coverage for some drugs ........................................108
SECTION 5 What if one of your drugs is not covered in the way you’d like it to be
covered? .........................................................................................................110
SECTION 6 What if your coverage changes for one of your drugs? .................................113
SECTION 7 What types of drugs are not covered by the plan? .........................................116
SECTION 8 Filling a prescription ......................................................................................117
SECTION 9 Part D drug coverage in special situations .....................................................118
SECTION 10 Programs on drug safety and managing medications ....................................119
CHAPTER 6: What you pay for your Part D prescription drugs ........................... 122
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7
SECTION 8
SECTION 9

Introduction ....................................................................................................123
What you pay for a drug depends on which drug payment stage you
are in when you get the drug ..........................................................................126
We send you reports that explain payments for your drugs and which
payment stage you are in................................................................................126
During the Deductible Stage, you pay the full cost of your [insert drug
tiers if applicable] drugs ................................................................................128
During the Initial Coverage Stage, the plan pays its share of your drug
costs, and you pay your share ........................................................................128
Costs in the Coverage Gap Stage ...................................................................133
During the Catastrophic Coverage Stage, the plan pays the full cost for
your covered Part D drugs .............................................................................134
Additional benefits information .....................................................................134
Part D Vaccines. What you pay for depends on how and where you get
them................................................................................................................134

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

CHAPTER 7: Asking us to pay our share of a bill you have received for
covered medical services or drugs ................................................... 137
SECTION 1
SECTION 2
SECTION 3

Situations in which you should ask us to pay our share of the cost of
your covered services or drugs ......................................................................138
How to ask us to pay you back or to pay a bill you have received ................140
We will consider your request for payment and say yes or no ......................141

CHAPTER 8: Your rights and responsibilities ....................................................... 142
SECTION 1
SECTION 2

Our plan must honor your rights and cultural sensitivities as a member
of the plan ......................................................................................................143
You have some responsibilities as a member of the plan ..............................148

CHAPTER 9: What to do if you have a problem or complaint (coverage
decisions, appeals, complaints) ........................................................ 150
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5

Introduction ....................................................................................................151
Where to get more information and personalized assistance .........................151
To deal with your problem, which process should you use? .........................152
A guide to the basics of coverage decisions and appeals...............................153
Your medical care: How to ask for a coverage decision or make an
appeal of a coverage decision ........................................................................156
SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or
make an appeal...............................................................................................163
SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the
doctor is discharging you too soon ................................................................173
SECTION 8 How to ask us to keep covering certain medical services if you think
your coverage is ending too soon...................................................................180
SECTION 9 Taking your appeal to Level 3 and beyond ....................................................186
SECTION 10 How to make a complaint about quality of care, waiting times,
customer service, or other concerns ...............................................................188
CHAPTER 10: Ending your membership in the plan ............................................. 192
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5

Introduction to ending your membership in our plan ....................................193
When can you end your membership in our plan? ........................................193
How do you end your membership in our plan? ............................................196
Until your membership ends, you must keep getting your medical
services and drugs through our plan ..............................................................196
[Insert 2024 plan name] must end your membership in the plan in
certain situations ............................................................................................197

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

CHAPTER 11: Legal notices .................................................................................... 200
SECTION 1
SECTION 2
SECTION 3

Notice about governing law ...........................................................................201
Notice about nondiscrimination .....................................................................201
Notice about Medicare Secondary Payer subrogation rights .........................201

CHAPTER 12: Definitions of important words ....................................................... 202

CHAPTER 1:

Getting started as a member

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

SECTION 1

Introduction

Section 1.1

You are enrolled in [insert 2024 plan name], which is a
Medicare HMO [insert if applicable: Point-of-Service Plan]

You are covered by Medicare, and you have chosen to get your Medicare health care and your
prescription drug coverage through our plan, [insert 2024 plan name]. We are required to
cover all Part A and Part B services. However, cost sharing and provider access in this plan
differ from Original Medicare.
[Insert 2024 plan name] is a Medicare Advantage HMO Plan (HMO stands for Health
Maintenance Organization) [insert if applicable: with a Point-of-Service (POS) option]
approved by Medicare and run by a private company. [Insert if applicable: Point-of-Service
means you can use providers outside the plan’s network for an additional cost. (See Chapter 3,
Section 2.4 for information about using the Point-of-Service option.)]
Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the
Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility
requirement. Please visit the Internal Revenue Service (IRS) website at:
www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.
[I-SNPs and C-SNPs use the following language for Section 1.1 in place of the language
above:
Section 1.1

You are currently enrolled in [insert 2024 plan name], which is
a specialized Medicare Advantage Plan (Special Needs Plan)

You are covered by Medicare, and you have chosen to get your Medicare health care and your
prescription drug coverage through our plan, [insert 2024 plan name].]
[Insert if applicable: [Insert 2024 plan name] is a Medicare Advantage HMO Plan (HMO
stands for Health Maintenance Organization) [insert if applicable: with a Point-of-Service
(POS) option] approved by Medicare and run by a private company. [Insert if applicable:
Point-of-Service means you can use providers outside the plan’s network for an additional
cost. (See Chapter 3, Section 2.4 for information about using the Point-of-Service option.)]]
[I-SNPs: insert the following two paragraphs:
[Insert 2024 plan name] is a specialized Medicare Advantage Plan (a Medicare Advantage
Special Needs Plan), which means its benefits are designed for people with special health care
needs. [Insert 2024 plan name] is designed for people who live in an institution (like a nursing
home) and/or live in the community but who need a level of care that is usually provided in a
nursing home.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

Our plan includes providers who specialize in treating patients who need this level of care. As a
member of the plan, you get specially tailored benefits and have all your care coordinated
through our plan.]
[C-SNPs: insert the following two paragraphs:
[Insert 2024 plan name] is a specialized Medicare Advantage Plan (a Medicare Special Needs
Plan), which means its benefits are designed for people with special health care needs. [Insert
2024 plan name] is designed to provide additional health benefits that specifically help people
who have [insert condition(s)].
Our plan includes providers who specialize in treating [insert condition(s)]. It also includes
health programs designed to serve the specialized needs of people with [insert as applicable: this
condition OR these conditions]. In addition, our plan covers prescription drugs to treat most
medical conditions, including the drugs that are usually used to treat [insert condition(s)]. As a
member of the plan, you get benefits specially tailored to your condition and have all your care
coordinated through our plan.]
Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the
Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility
requirement. Please visit the Internal Revenue Service (IRS) website at:
www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.
Section 1.2

What is the Evidence of Coverage document about?

This Evidence of Coverage document tells you how to get your medical care and prescription
drugs. It explains your rights and responsibilities, what is covered, what you pay as a member of
the plan, and how to file a complaint if you are not satisfied with a decision or treatment.
The words coverage and covered services refer to the medical care and services and the
prescription drugs available to you as a member of [insert 2024 plan name].
It’s important for you to learn what the plan’s rules are and what services are available to you.
We encourage you to set aside some time to look through this Evidence of Coverage document.
If you are confused, concerned, or just have a question, please contact Member Services.
Section 1.3

Legal information about the Evidence of Coverage

This Evidence of Coverage is part of our contract with you about how [insert 2024 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 2024 plan name]
between January 1, 2024 and December 31, 2024.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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 2024 plan name] after December 31, 2024. We
can also choose to stop offering the plan in your service area, after December 31, 2024.
Medicare (the Centers for Medicare & Medicaid Services) must approve [insert 2024 plan
name] each year. You can continue each year 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 both Medicare Part A and Medicare Part B

•

-- and -- you live in our geographic service area (Section 2.2 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.] Incarcerated
individuals are not considered living in the geographic service area even if they are
physically located in it.

•

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

•

[I-SNPs and C-SNPs insert: -- and -- you meet the special eligibility requirements
described below.]

[I-SNPs and C-SNPs insert this section as applicable to your plan type:
Special eligibility requirements for our plan
[Chronic/disabling condition SNPs, insert: Our plan is designed to meet the specialized needs of
people who have certain medical conditions. To be eligible for our plan, you must have [insert
condition(s)].]
[Institutional SNPs, insert: Our plan is designed to meet the specialized needs of people who
need a level of care that is usually provided in a nursing home.]
[Plans that limit enrollment to those residing in an institution, insert: To be eligible for our plan,
you must live in a nursing home available through our plan.] [Insert as appropriate: Please see
the plan’s Provider Directory for a list of our contracted nursing homes or call Member Services
and ask us to send you a list. OR Here is a list of our contracted nursing homes:
•

[Insert list of contracted facilities]]]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

[Plans that also enroll those who are Nursing Facility Level of Care (NFLOC) certified, insert:
To be eligible for our plan, you must meet one of the two requirements listed below.
•

You live in a nursing home available through our plan. [Insert as appropriate: Please see
the plan’s Provider Directory for a list of our contracted nursing homes or call Member
Services and ask us to send you a list. OR Here is a list of our contracted nursing homes:
o [Insert list of contracted facilities]

•

-or – you live at home and our plan has obtained certification that you need the type of
care that is usually provided in a nursing home.]]

•

[I-SNPs and C-SNPs, insert: Please note: If you lose your eligibility but can reasonably
be expected to regain eligibility within [Insert number 1-6. Plans may choose any length
of time from one to six months for deeming continued eligibility, as long as they apply the
criteria consistently across all members and fully inform members of the policy]month(s), then you are still eligible for membership in our plan (Chapter 4, Section 2.1
tells you about coverage and cost sharing during a period of deemed continued
eligibility).]

Section 2.2

Here is the plan service area for [insert 2024 plan name]

[Insert 2024 plan name] is available only to individuals who live in our plan service area. To
remain a member of our plan, you [if a continuation area is offered under 42 CFR 422.54,
insert: generally here, and add a sentence describing the continuation area] 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. Use the county name only if approved for the entire county. For an approved
partial county, use the county name plus the approved zip code(s). Examples of the format for
describing the service area are provided below. If needed, plans may insert more than one row
to describe their service area.
Our service area includes all 50 states
Our service area includes these states: [insert states]
Our service area includes these counties in [insert state]: [insert counties]
Our service area includes these parts of counties in [insert state]: [insert county], the following
zip codes only [insert zip codes]]
[Optional information: 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]]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

If you plan to move out of the service area, you cannot remain a member of this plan. Please
contact Member Services to see if we have a plan in your new area. When you move, you will
have a Special Enrollment Period that will allow you to switch to Original Medicare or 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 2.3

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 2024 plan
name] if you are not eligible to remain a member on this basis. [Insert 2024 plan name] must
disenroll you if you do not meet this requirement.

SECTION 3

Important membership materials you will receive

Section 3.1

Your plan membership card

[Plans that use separate membership cards for health and drug coverage should edit the
following section to reflect the use of multiple cards.]
While you are a member of our plan, you must use your membership card whenever you get
services covered by this plan and 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.)]
Do NOT use your red, white, and blue Medicare card for covered medical services while you are
a member of this plan. If you use your Medicare card instead of your [insert 2024 plan name]
membership card, you may have to pay the full cost of medical services yourself. Keep your
Medicare card in a safe place. You may be asked to show it if you need hospital services, hospice
services, or participate in Medicare approved clinical research studies also called clinical trials.
If your plan membership card is damaged, lost, or stolen, call Member Services right away and
we will send you a new card.
Section 3.2

Provider Directory

[Plans with combined provider and pharmacy directories may combine and edit the provider
and pharmacy directory sections (including section titles) to describe the combined document.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

Plans should renumber sections as needed and revise references to Provider Directory to use the
actual name of the document throughout the model.]
The Provider Directory lists our current network providers [insert if applicable: and durable
medical equipment suppliers]. Network providers are the doctors and other health care
professionals, medical groups, [insert if applicable: durable medical equipment suppliers,]
hospitals, and other health care facilities that have an agreement with us to accept our payment
and any plan cost sharing as payment in full.
You must use network providers to get your medical care and services. [Plans with sub-networks
(e.g., limiting members to providers within their PCP’s sub-network) insert a brief explanation
of the additional limitations of your sub-network structure. Refer to the current Medicare
Advantage and Section 1876 Cost Plan Network Adequacy Guidance for guidance on subnetworks.] If you go elsewhere without proper authorization you will have to pay in full. The
only exceptions are emergencies, urgently needed services when the network is not available
(that is, in situations when it is unreasonable or not possible to obtain services in-network), outof-area dialysis services, and cases in which [insert 2024 plan name] authorizes use of out-ofnetwork providers.
[Plans with a Point-of-Service (POS) option must briefly describe the POS option here. The
details of the POS should be addressed in Chapter 3.]
[Insert as applicable: We included a copy of our Provider Directory in the envelope with this
document.] [Insert as applicable: We [insert as applicable: also] included a copy of our Durable
Medical Equipment Supplier Directory in the envelope with this document.] [The most recent list
of providers [insert as applicable: and suppliers] is [insert as applicable: also] available on our
website at [insert URL].]
If you don’t have your copy of the Provider Directory, you can request a copy (electronically or
in hardcopy form) from Member Services. Requests for hard copy Provider Directories will be
mailed to you within three business days.
Section 3.3

Pharmacy Directory

[Plans with combined provider and pharmacy directories may combine and edit the provider
and pharmacy directory sections (including section titles) to describe the combined document.
Plans should renumber sections as needed and revise references to the Pharmacy Directory to
use the actual name of the document throughout the model.]
The pharmacy directory lists our network pharmacies. Network pharmacies are all of the
pharmacies that have agreed to fill covered prescriptions for our plan members. You can use the
Pharmacy Directory to find the network pharmacy you want to use. See Chapter 5, Section 2.5
for information on when you can use pharmacies that are not in the plan’s network.
[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,

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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. 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 3.4

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 under the Part D benefit included in [insert 2024
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 2024 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.

SECTION 4

Your monthly costs for [insert 2024 plan name]

[Plans with no premiums and whose members would never have to pay a late enrollment penalty
(e.g., an I-SNP that enrolls full-benefit duals under an HCBS waiver and has $0 premium), may
edit Section 4 as needed.]
[Delete Optional Supplemental Benefit Premium bullet if your plan doesn't offer optional
supplemental benefits. Renumber remaining sections as appropriate.]
Your costs may include the following:
• Plan Premium (Section 4.1)
• Monthly Medicare Part B Premium (Section 4.2)
• Optional Supplemental Benefit Premium (Section 4.3)
• Part D Late Enrollment Penalty (Section 4.4)
• Income Related Monthly Adjusted Amount (Section 4.5)

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

In some situations, your plan premium could be less
[Plans with no monthly premium: Omit this subsection.]
[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.
Medicare Part B and Part D premiums differ for people with different incomes. If you have
questions about these premiums review your copy of Medicare & You 2024 handbook, the
section called 2024 Medicare Costs. If you need a copy, you can download it from the Medicare
website (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 4.1

Plan premium

As a member of our plan, you pay a monthly plan premium. [Select one of the following: For
2024, the monthly premium for [insert 2024 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 2024 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].]
[Plans with no premium should replace the preceding paragraph with: You do not pay a
separate monthly plan premium for [insert 2024 plan name].]
[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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

Section 4.2

Monthly Medicare Part B Premium

Many members are required to pay other Medicare premiums
[Plans that include a Part B premium reduction benefit may describe the benefit within this
section.]
[Plans with no monthly premium, omit: In addition to paying the monthly plan premium,] you
must continue paying your Medicare premiums to remain a member of the plan. This
includes your premium for Part B. It may also include a premium for Part A which affects
members who aren’t eligible for premium free Part A.
Section 4.3

Optional Supplemental Benefit Premium

If you signed up for extra benefits, also called optional supplemental benefits, then you pay an
additional premium each month for these extra benefits. See Chapter 4, Section 2.2 for details.
[If the plan describes optional supplemental benefits within Chapter 4, then the plan must
include the premium amounts for those benefits in this section.]
[Delete Chapter 1, Section 4.3 if your plan doesn't offer optional supplemental benefits.
Renumber remaining sections as appropriate.]
Section 4.4

Part D Late Enrollment Penalty

Some members are required to pay a Part D late enrollment penalty. The Part D late enrollment
penalty is an additional premium that must be paid for Part D coverage 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 cost of the late enrollment
penalty depends on how long you went without Part D or other 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 or quarterly premium. [Plans that
do not allow quarterly premium payments, omit the quarterly portion of the sentence above.]
When you first enroll in [insert 2024 plan name], we let you know the amount of the penalty.
[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 lose your prescription drug benefits.]
[Plans with no plan premium, delete the first sentence in the paragraph above and continue with
the remainder of the paragraph.]
You will not have to pay it if:
•
•

You receive “Extra Help” from Medicare to pay for your prescription drugs.
You have gone less than 63 days in a row without creditable coverage.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

•

You have had creditable drug coverage through another source such as a former
employer, union, TRICARE, or 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.
o Note: Any notice must state that you had creditable prescription drug coverage that is
expected to pay as much as Medicare’s standard prescription drug plan pays.
o Note: The following are not creditable prescription drug coverage: prescription
drug discount cards, free clinics, and drug discount websites.

Medicare determines the amount of the penalty. Here is how it works:
•

If you went 63 days or more without Part D or other creditable prescription drug
coverage after you were first eligible to enroll in Part D, the plan will count the number
of full months that you did not have coverage. The penalty is 1% for every month that
you did not 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 2024, this average
premium amount is $[insert 2024 national base beneficiary premium] OR For 2023, this
average premium amount was $[insert 2023 national base beneficiary premium]. This
amount may change for 2024.]

•

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.

•

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, even if you change plans.

•

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.

If you disagree about your Part D late enrollment penalty, you or your representative can
ask for a review. Generally, you must request this review within 60 days from the date on the
first letter you receive stating you have to pay a late enrollment penalty. However, if you were

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Chapter 1 Getting started as a member

paying a penalty before joining our plan, you may not have another chance to request a review of
that late enrollment penalty.
[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 4.5

Income Related Monthly Adjustment Amount

Some members may be required to pay an extra charge, known as the Part D Income Related
Monthly Adjustment Amount, also known as IRMAA. The extra charge is figured out using your
modified adjusted gross income as reported on your IRS tax return from 2 years ago. If this
amount is above a certain amount, you’ll pay the standard premium amount and the additional
IRMAA. For more information on the extra amount you may have to pay based on your income,
visit https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drugcoverage/monthly-premium-for-drug-plans.
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. 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. If you do not pay the extra amount, you will be
disenrolled from the plan and lose prescription drug coverage.
If you disagree about paying an extra amount, 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 1-800325-0778).

SECTION 5

More information about your monthly premium

Section 5.1

There are several ways you can pay your plan premium

[Plans indicating in Section 4.1 that there is no monthly premium: Rename this section, “If you
pay a Part D late enrollment penalty, there are several ways you can pay your penalty,” and use
the alternative text as instructed below.]
There are [insert number of payment options] ways you can pay your plan premium.
[Plans without a monthly premium: Replace the preceding two paragraphs with the following:
There are [insert number of payment options] ways you can pay the penalty. [Plans must
indicate how the member can inform the plan of the procedure for changing that choice.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

Option 1: Paying by check
[Insert plan specifics regarding premium/penalty payment intervals (e.g., monthly, quarterlyplease note that members 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 5th 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 members 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]: Having your [plans with a premium insert: plan premium]
[plans without a premium insert: Part D late enrollment penalty] taken out of your
monthly Social Security check
Changing the way you pay your premium. If you decide to change the option by which
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. To change your payment method, [Plans
must indicate how the member can inform the plan of the procedure for changing that choice.]
What to do if you are having trouble paying your [plans with a premium insert:
plan premium] [plans without a premium insert: Part D late enrollment penalty]
[Plans that do not disenroll members for non-payment may modify this section as needed.]
Your [plans with a premium insert: plan premium] [plans without a premium insert: Part D late
enrollment penalty] is due in our office by the [insert day of the month]. [Plans with no premium
insert: If you are required to pay a Part D late enrollment penalty, that penalty is due in our
office by the [insert day of the month]. If we have not received your payment 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 [plans with a premium insert: premium] [plans without a premium insert: Part
D late enrollment penalty, if owed,] within [insert length of plan grace period]. If you are

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Chapter 1 Getting started as a member

required to pay a Part D late enrollment penalty, you must pay the penalty to keep your
prescription drug coverage.
If you are having trouble paying your [plans with a premium insert: premium] [plans without a
premium insert: Part D late enrollment penalty, if owed,] on time, please contact Member
Services to see if we can direct you to programs that will help with your costs.
If we end your membership because you did not pay your [plans with a premium insert:
premium] [plans without a premium insert: Part D late enrollment penalty, if owed], you will
have health coverage under Original Medicare. In addition, 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. (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 [plans with
a premium insert: premiums] [plans without a premium insert: the penalty] you have not paid.
[Insert one or both statements as applicable for the plan: We have the right to pursue collection
of the amount 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 can make a complaint (also called
a grievance); see Chapter 9 for how to file 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 [plans with a premium
insert: plan premium] [plans without a premium insert: Part D late enrollment penalty, if owed,]
within our grace period, you can make a complaint. For complaints, we will review our decision
again. Chapter 9, Section 10 of this document tells how to make a complaint, or you can call us at
[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 5.2

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.
[Plans with no premium replace the previous paragraph with the following: However, in some
cases, you may be able to stop paying a late enrollment penalty, if owed, or need to start paying a

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

late enrollment penalty. This could happen if you become eligible for the “Extra Help” program
or if you lose your eligibility for the “Extra Help” program during the year:
•

If you currently pay the Part D late enrollment penalty and become eligible for “Extra
Help” during the year, you would be able to stop paying your penalty.

•

If you lose “Extra Help”, you may be subject to the late enrollment penalty if you go 63
days or more in a row without Part D or other creditable prescription drug coverage.

You can find out more about the “Extra Help” program in Chapter 2, Section 7.]

SECTION 6

Keeping your plan membership record up to date

[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 [insert as appropriate: including your
Primary Care Provider/Medical Group/IPA].
The doctors, hospitals, pharmacists, and other providers in the plan’s network need to have
correct information about you. These network providers use your membership record to
know what services and 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 health insurance coverage you have (such as from your employer,
your spouse or domestic partner’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 you receive care in an out-of-area or out-of-network hospital or emergency room

•

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

•

If you are participating in a clinical research study (Note: You are not required to tell
your plan about the clinical research studies, you intend to participate in, but we
encourage you to do so)

If any of this information changes, please let us know by calling Member Services. [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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

SECTION 7

How other insurance works with our plan

Other insurance
[Plans collecting information by phone revise heading and section as needed to reflect process.]
Medicare requires that we collect information from you about any other medical or drug
insurance coverage that you have. That’s because we must coordinate any other coverage you
have with your benefits under our plan. This is called Coordination of Benefits.
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. 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.
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. If you have other
insurance, tell your doctor, hospital, and pharmacy.
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):
o 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.
o If you’re over 65 and you or your spouse or domestic partner 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

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

•

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.

CHAPTER 2:

Important phone numbers
and resources

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

SECTION 1

[Insert 2024 plan name] contacts
(how to contact us, including how to reach Member
Services)

How to contact our plan’s Member Services
For assistance with claims, billing, or member card questions, please call or write to [insert 2024
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

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 C and Part D issues indicated
below, you may combine the appropriate sections and revise the section titles and paragraphs as
needed.]
How to contact us when you are asking for a coverage decision or appeal about
your medical care
A coverage decision is a decision we make about your benefits and coverage or about the
amount we will pay for your medical services or 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 asking for coverage decisions or appeals about your medical care or Part D
prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)).
[If the plan has different phone numbers for coverage decisions and appeals or for medical care
and prescription drugs, the plan should duplicate the chart as necessary, labeling
appropriately.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

Coverage Decisions and Appeals for Medical Care or 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 24hour lines here.] [Note: If you have a different number for accepting
expedited organization determinations, also include that number
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 free. [Insert days and hours of operation]
[Note: If you have a different TTY number for accepting expedited
organization determinations, also include that number here.]

FAX

[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited organization determinations, also
include that number here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited organization determinations, also include that address
here.]
[Note: plans may add email addresses here.]

WEBSITE

[Optional: Insert URL]

How to contact us when you are making a complaint about your medical care
You can make a complaint about us or one of our network providers or pharmacies, including
a complaint about the quality of your care. This type of complaint does not involve coverage
or payment disputes. For more information on making a complaint about your medical care,
see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)).
[If plan has different numbers for complaints regarding providers and pharmacies, duplicate the
chart below to account for the different numbers.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

Complaints About Medical Care – 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 24hour lines here.] [Note: If you have a different number for accepting
expedited grievances, also include that number here.]

TTY

FAX

[Optional: insert fax number] [Note: If you have a different fax
number for accepting expedited grievances, also include that number
here.]

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited grievances, also include that address here.]
[Note: plans may add email addresses here.]

MEDICARE
WEBSITE

You can submit a complaint about [insert 2024 plan name] directly
to Medicare. To submit an online complaint to Medicare, go to
www.medicare.gov/MedicareComplaintForm/home.aspx.

Where to send a request asking us to pay for our share of the cost for medical
care or a drug you have received
If you have received a bill or paid for services (such as a provider bill) that you think we
should pay for, you may need to ask us for reimbursement or to pay the provider bill. See
Chapter 7 (Asking us to pay our share of a bill you have received for covered medical
services or 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 9 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.
[Plans with different addresses and/or numbers for Part C and Part D claims may modify the
table below or add a second table as needed.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

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 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 Advantage organizations
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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

Medicare – Contact Information

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

www.medicare.gov
This is the official government website for Medicare. It gives you upto-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 documents 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.
You can also use the website to tell Medicare about any complaints you
have about [insert 2024 plan name]:
• Tell Medicare about your complaint: You can submit a
complaint about [insert 2024 plan name] directly to Medicare.
To submit a complaint to Medicare, go to
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 and review the information with
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

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

have the option of including a separate exhibit to list information for all states in which the plan
is filed and should refer 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 an independent (not connected with any insurance
company or health plan) 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 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 with Medicare questions or problems and help you understand your Medicare plan
choices and answer questions about switching plans.
METHOD TO ACCESS SHIP and OTHER RESOURCES:
•
•
•

Visit https://www.shiphelp.org (Click on SHIP LOCATOR in middle of
page)
Click on Talk to Someone in the middle of the homepage
You now have the following options
o Option #1: You can have a live chat with a 1-800-MEDICARE
representative
o Option #2: You can select your STATE from the dropdown
menu and click GO. This will take you to a page with phone
numbers and resources specific to your state.

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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

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

WRITE

[Insert address]
[Note: plans may add email addresses here.]

WEBSITE

[Insert URL]

SECTION 4

Quality Improvement Organization

[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 refer 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 the 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 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] in any of these situations:
•

You have a complaint about the quality of care you have received.

•

You think coverage for your hospital stay is ending too soon.

•

You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.

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]

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Chapter 2 Important phone numbers and resources

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

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. 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 8:00 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 8:00 am to 7:00 pm, Monday through Friday.

WEBSITE

www.ssa.gov

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Chapter 2 Important phone numbers and resources

SECTION 6

Medicaid

[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 refer 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. The programs offered through Medicaid help people with Medicare pay
their Medicare costs, such as their Medicare premiums. These Medicare Savings Programs
include:
•

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+).)

•

Qualifying 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]

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Chapter 2 Important phone numbers and resources

SECTION 7

Information about programs to help people pay for
their prescription drugs

The Medicare.gov website (https://www.medicare.gov/drug-coverage-part-d/costs-for-medicaredrug-coverage/costs-in-the-coverage-gap/5-ways-to-get-help-with-prescription-costs) provides
information on how to lower your prescription drug costs. For people with limited incomes, there
are also other programs to assist, described below.
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, yearly
deductible, and prescription copayments. This “Extra Help” also counts toward your out-ofpocket costs.
If you automatically qualify for “Extra Help” Medicare will mail you a letter. You will not have
to apply. If you do not automatically qualify 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 8 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 a
process for 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 members 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 the payment directly to the state. Please contact
Member Services if you have questions.

[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

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Chapter 2 Important phone numbers and resources

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 1-800MEDICARE (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 www.medicare.gov for
more information.]
What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?
[Plans without an SPAP in their state(s), should delete this section.]
Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums
and/or other drug costs. 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 70% discount on covered brand name drugs. Also, the plan pays 5% of the costs
of brand drugs in the coverage gap. The 70% discount and the 5% 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 on the ADAP formulary qualify for prescription cost-sharing assistance through the
[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 change plans, please notify your local ADAP
enrollment worker so you can continue to receive assistance. For information on eligibility
criteria, covered drugs, or how to enroll in the program, please call [insert State-specific ADAP
contact information].
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 refer 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.

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Chapter 2 Important phone numbers and resources

[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
receive your Medicare through the Railroad Retirement Board, it is important that you let them
know if you move or change your mailing address. If you have questions regarding your benefits
from the Railroad Retirement Board, contact the agency.
Method

Railroad Retirement Board – Contact Information

CALL

1-877-772-5772
Calls to this number are free.
If you press “0,” you may speak with an RRB representative from
9:00 am to 3:30 pm, Monday, Tuesday, Thursday, and Friday, and
from 9:00 am to 12:00 pm on Wednesday.
If you press “1”, you may access the automated RRB HelpLine and
recorded information 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.

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Chapter 2 Important phone numbers and resources

Method

Railroad Retirement Board – Contact Information

WEBSITE

rrb.gov/

SECTION 9

Do you have group insurance or other health
insurance from an employer?

If you (or your spouse or domestic partner) get benefits from your (or your spouse or domestic
partner’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 or domestic partner’s) employer or retiree health benefits, premiums, or the
enrollment period. (Phone numbers for Member Services are printed on the back cover of this
document.) 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 or domestic partner’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
for your medical services

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Chapter 3 Using the plan for your medical services

SECTION 1

Things to know about getting your medical care as a
member of our plan

This chapter explains what you need to know about using the plan to get your medical care
covered. It gives definitions of terms and explains the rules you will need to follow to get the
medical treatments, services, equipment, prescription drugs, and other medical care that are
covered by the plan.
For the details on what medical care is covered by our plan and how much you pay when you
get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what
is covered and what you pay).
Section 1.1

What are network providers and covered services?

•

Providers are doctors and other health care professionals licensed by the state to provide
medical services and care. The term providers also includes hospitals and other health
care facilities.

•

Network providers are the doctors and other health care professionals, medical groups,
hospitals, and other health care facilities that have an agreement with us to accept our
payment and your cost-sharing amount as payment in full. We have arranged for these
providers to deliver covered services to members in our plan. The providers in our
network bill us directly for care they give you. When you see a network provider, you
pay only your share of the cost for their services.

•

Covered services include all the medical care, health care services, supplies equipment,
and Prescription Drugs that are covered by our plan. Your covered services for medical
care are listed in the benefits chart in Chapter 4. Your covered services for prescription
drugs are discussed in Chapter 5.

Section 1.2

Basic rules for getting your medical care covered by the plan

As a Medicare health plan, [insert 2024 plan name] must cover all services covered by Original
Medicare and must follow Original Medicare’s coverage rules.
[Insert 2024 plan name] will generally cover your medical care as long as:
•
•

•

The care you receive is included in the plan’s Medical Benefits Chart (this chart is in
Chapter 4 of this document).
The care you receive is considered medically necessary. Medically necessary means
that the services, supplies, equipment, or drugs are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of medical practice.
[Plans may omit or edit the PCP-related bullets as necessary] You have a network
primary care provider (a PCP) who is providing and overseeing your care. As a
member of our plan, you must choose a network PCP (for more information about this,
see Section 2.1 in this chapter).

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Chapter 3 Using the plan for your medical services

•

o In most situations, [insert as applicable: your network PCP OR our plan] must give
you approval in advance before you can use other providers in the plan’s network,
such as specialists, hospitals, skilled nursing facilities, or home health care
agencies. This is called giving you a referral. For more information about this, see
Section 2.3 of this chapter.
o Referrals from your PCP are not required for emergency care or urgently needed
services. There are also some other kinds of care you can get without having
approval in advance from your PCP (for more information about this, see Section
2.2 of this chapter).
[Plans with a POS option may edit the network provider bullets as necessary.] You must
receive your care from a network provider (for more information about this, see
Section 2 in this chapter). In most cases, care you receive from an out-of-network
provider (a provider who is not part of our plan’s network) will not be covered. This
means that you will have to pay the provider in full for the services furnished. Here are
three exceptions:
o The plan covers emergency care or urgently needed services that you get from an
out-of-network provider. For more information about this, and to see what
emergency or urgently needed services means, see Section 3 in this chapter.
o If you need medical care that Medicare requires our plan to cover but there are no
specialists in our network that provide this care, you can get this care from an outof-network provider at the same cost sharing you normally pay in-network. [Plans
may specify if authorization should be obtained from the plan prior to seeking
care.] In this situation, you will pay the same as you would pay if you got the care
from a network provider. For information about getting approval to see an out-ofnetwork doctor, see Section 2.4 in this chapter.
o The plan covers kidney dialysis services that you get at a Medicare-certified
dialysis facility when you are temporarily outside the plan’s service area or when
your provider for this service is temporarily unavailable or inaccessible. The cost
sharing you pay the plan for dialysis can never exceed the cost sharing in Original
Medicare. If you are outside the plan’s service area and obtain the dialysis from a
provider that is outside the plan’s network, your cost sharing cannot exceed the cost
sharing you pay in-network. However, if your usual in-network provider for dialysis
is temporarily unavailable and you choose to obtain services inside the service area
from a provider outside the plan’s network the cost sharing for the dialysis may be
higher.

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Chapter 3 Using the plan for your medical services

SECTION 2

Use providers in the plan’s network to get your
medical care

Section 2.1

You [insert as applicable: may OR must] choose a Primary Care
Provider (PCP) to provide and oversee your medical care

[Note: Insert this section only if plan uses PCPs. Plans may edit this section to refer to a
Physician of Choice (POC) instead of PCP.]
What is a PCP and what does the PCP do for you?
[Plans should describe the following in the context of their plans:
•
•
•
•
•

What is a PCP?
What types of providers may act as a PCP?
Explain the role of a PCP in your plan.
What is the role of the PCP in coordinating covered services?
What is the role of the PCP in making decisions about or obtaining prior authorization
(PA), if applicable?]

How do you choose your PCP?
[Plans should describe how to choose a PCP.]
Changing your PCP
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might
leave our plan’s network of providers and you would have to find a new PCP. [Explain if the
member changes their PCP this may result in being limited to specific specialists or hospitals to
which that PCP refers (i.e., sub-network, referral circles). Also noted in Section 2.3 below.]
[Plans should describe how to change a PCP and indicate when that change will take effect
(e.g., on the first day of the month following the date of the request, immediately upon receipt of
request, etc.).]
Section 2.2

What kinds of medical care can you get without a referral from
your PCP?

[Note: Insert this section only if plans use PCPs or require referrals to network providers.]
You can get the services listed below without getting approval in advance from your PCP.
•

Routine women’s health care, which includes breast exams, screening mammograms (xrays of the breast), Pap tests, and pelvic exams [insert if applicable: as long as you get
them from a network provider].

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Chapter 3 Using the plan for your medical services

•

Flu shots, COVID-19 vaccinations, [insert if applicable: Hepatitis B vaccinations, and
pneumonia vaccinations] [insert if appropriate: as long as you get them from a network
provider]

•

Emergency services from network providers or from out-of-network providers

•

Urgently needed services are covered services that are not emergency services, provided
when the network providers are temporarily unavailable or inaccessible or when the
enrollee is out of the service area. For example, you need immediate care during the
weekend. Services must be immediately needed and medically necessary.

•

Kidney dialysis services that you get at a Medicare-certified dialysis facility when you
are temporarily outside the plan’s service area. If possible, please call Member Services
before you leave the service area so we can help arrange for you to have maintenance
dialysis while you are away.

•

[Plans should add additional bullets as appropriate.]

Section 2.3

How to get care from specialists and other network providers

A specialist is a doctor who provides health care services for a specific disease or part of the
body. There are many kinds of specialists. Here are a few examples:
•

Oncologists care for patients with cancer.

•

Cardiologists care for patients with heart conditions.

•

Orthopedists care for patients with certain bone, joint, or muscle conditions.

[Plans should describe how members access specialists and other network providers, including:
•

What is the role (if any) of the PCP in referring members to specialists and other
providers?

•

Include an explanation of the process for obtaining PA, including who makes the PA
decision (e.g., the plan, PCP, another entity) and who is responsible for obtaining the PA
(e.g., PCP, member). Refer members to Chapter 4, Section 2.1 for information about
which services require PA.

•

Explain if the selection of a PCP results in being limited to specific specialists or
hospitals to which that PCP refers (i.e., sub-network, referral circles).]

What if a specialist or another network provider leaves our plan?
We may make changes to the hospitals, doctors, and specialists (providers) that are part of your
plan during the year. If your doctor or specialist leaves your plan you have certain rights and
protections that are summarized below:

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Chapter 3 Using the plan for your medical services

•

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 our network does not have a qualified specialist for a plan covered service,
we must cover that service at in-network cost-sharing. [Plans should indicate if prior
authorization is needed.]

•

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 to manage your care.

•

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 a quality of care complaint to the QIO, a quality of care grievance to the plan,
or both. Please see Chapter 9.

Section 2.4

How to get care from out-of-network providers

[Plans with a POS option: Describe POS option here. Tell members under what circumstances
they may obtain services from out-of-network providers and what restrictions apply. General
information (no specific dollar amounts) about cost sharing applicable to the use of out-ofnetwork providers in HMO/POS plans should be inserted here, with reference to the benefits
chart where detailed information can be found.]
[Plans without a POS option: Tell members under what circumstances they may obtain services
from out-of-network providers (e.g., when providers of specialized services are not available in
network). Describe the process for obtaining authorization, including who is responsible for
obtaining authorization.] [Note: Members are entitled to receive services from out-of-network
providers for emergency or urgently needed services. In addition, plans must cover dialysis
services for ESRD members who have traveled outside the plans service area and are not able to
access contracted ESRD providers.]

SECTION 3

How to get services when you have an emergency or
urgent need for care or during a disaster

Section 3.1

Getting care if you have a medical emergency

What is a medical emergency and what should you do if you have one?
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 your loss of life (and, if you are a pregnant woman, loss of an unborn child),

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Chapter 3 Using the plan for your medical services

loss of a limb or function of a limb, or loss of or serious impairment to a bodily function. The
medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly
getting worse.
If you have a medical emergency:
•

Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval or a
referral first from your PCP. You do not need to use a network doctor. You may get
covered emergency medical care whenever you need it, anywhere in the United States or
its territories, and from any provider with an appropriate state license even if they are not
part of our network [plans may modify this sentence to identify whether this coverage is
within the U.S. or world-wide emergency/urgent coverage].

•

[Plans add if applicable: As soon as possible, make sure that our plan has been told
about your emergency. We need to follow up on your emergency care. You or someone
else should call to tell us about your emergency care, usually within 48 hours. [Plans
must provide either the phone number and days and hours of operation or explain where
to find the number (e.g., on the back the plan membership card).]]

What is covered if you have a medical emergency?
Our plan covers ambulance services in situations where getting to the emergency room in any
other way could endanger your health. We also cover medical services during the emergency.
The doctors who are giving you emergency care will decide when your condition is stable,
and the medical emergency is over.
[Plans may modify this paragraph as needed to address the post-stabilization care for your
plan.] After the emergency is over you are entitled to follow-up care to be sure your condition
continues to be stable. Your doctors will continue to treat you until your doctors contact us and
make plans for additional care. Your follow-up care will be covered by our plan.
If your emergency care is provided by out-of-network providers, we will try to arrange for
network providers to take over your care as soon as your medical condition and the
circumstances allow.
What if it wasn’t a medical emergency?
Sometimes it can be hard to know if you have a medical emergency. For example, you might go
in for emergency care – thinking that your health is in serious danger – and the doctor may say
that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long
as you reasonably thought your health was in serious danger, we will cover your care.
However, after the doctor has said that it was not an emergency, we will cover additional care
only if you get the additional care in one of these two ways:

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•

You go to a network provider to get the additional care.

•

– or – The additional care you get is considered urgently needed services and you follow
the rules for getting this urgent care (for more information about this, see Section 3.2
below).

Section 3.2

Getting care when you have an urgent need for services

What are urgently needed services?
An urgently needed service is a non-emergency situation requiring immediate medical care but
given your circumstances, it is not possible or not reasonable to obtain these services from a
network provider. The plan must cover urgently needed services provided out of network. Some
examples of urgently needed services are i) a severe sore throat that occurs over the weekend or
ii) an unforeseen flare-up of a known condition when you are temporarily outside the service
area.
[Plans must insert instructions for how to access urgently needed services (e.g., using urgent
care centers, a provider hotline, etc.).]
[Insert if applicable: Plans without world-wide emergency/urgent coverage as a supplemental
benefit: Our plan does not cover emergency services, urgently needed services, nor any other
services for care received outside of the United States and its territories.]
[Insert if applicable: Plans with world-wide emergency/urgent coverage as a supplemental
benefit: Our plan covers worldwide [Insert as applicable: emergency and urgent care OR
emergency OR urgent care] services outside the United States under the following circumstances
[insert details].]
Section 3.3

Getting care during a disaster

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President
of the United States declares a state of disaster or emergency in your geographic area, you are
still entitled to care from your plan.
Please visit the following website: [insert website] for information on how to obtain needed care
during a disaster.
If you cannot use a network provider during a disaster, your plan will allow you to obtain care
from out-of-network providers at in-network cost sharing. If you cannot use a network pharmacy
during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy.
Please see Chapter 5, Section 2.5 for more information.

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SECTION 4

What if you are billed directly for the full cost of your
services?

Section 4.1

You can ask us to pay our share of the cost of covered
services

If you have paid more than your plan cost-sharing for covered services, or if you have received a
bill for the full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a
bill you have received for covered medical services or drugs) for information about what to do.
Section 4.2

If services are not covered by our plan, you must pay the full
cost

[Insert 2024 plan name] covers all medically necessary services as listed in the Medical Benefits
Chart in Chapter 4 of this document. If you receive services not covered by our plan or services
obtained out-of-network and were not authorized, you are responsible for paying the full cost of
services.
For covered services that have a benefit limitation, you also pay the full cost of any services you
get after you have used up your benefit for that type of covered service. [Plans should explain
whether paying for costs once a benefit limit has been reached will count toward an out-ofpocket maximum.]

SECTION 5

How are your medical services covered when you are
in a clinical research study?

Section 5.1

What is a clinical research study?

A clinical research study (also called a clinical trial) is a way that doctors and scientists test new
types of medical care, like how well a new cancer drug works. Certain clinical research studies
are approved by Medicare. Clinical research studies approved by Medicare typically request
volunteers to participate in the study.
Once Medicare approves the study, and you express interest, someone who works on the study
will contact you to explain more about the study and see if you meet the requirements set by the
scientists who are running the study. You can participate in the study as long as you meet the
requirements for the study, and you have a full understanding and acceptance of what is involved
if you participate in the study.
If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the
covered services you receive as part of the study. If you tell us that you are in a qualified clinical
trial, then you are only responsible for the in-network cost sharing for the services in that trial. If
you paid more, for example, if you already paid the Original Medicare cost-sharing amount, we

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Chapter 3 Using the plan for your medical services

will reimburse the difference between what you paid and the in-network cost sharing. However,
you will need to provide documentation to show us how much you paid. When you are in a
clinical research study, you may stay enrolled in our plan and continue to get the rest of your
care (the care that is not related to the study) through our plan.
If you want to participate in any Medicare-approved clinical research study, you do not need to
tell us or to get approval from us [plans that do not use PCPs may delete the rest of this
sentence] or your PCP. The providers that deliver your care as part of the clinical research study
do not need to be part of our plan’s network of providers. Please note that this does not include
benefits for which our plan is responsible that include, as a component, a clinical trial or registry
to assess the benefit. These include certain benefits specified under national coverage
determinations (NCDs) and investigational device trials (IDE) and may be subject to prior
authorization and other plan rules.
Although you do not need to get our plan’s permission to be in a clinical research study, covered
for Medicare Advantage enrollees by Original Medicare, we encourage you to notify us in
advance when you choose to participate in Medicare-qualified clinical trials.
[For plans that offer their own studies insert the paragraph: Our plan also covers some clinical
research studies. For these studies, we will have to approve your participation. Participation in
the clinical research study is also voluntary.]
If you participate in a study that Medicare [plans that conduct or cover clinical trials that are not
approved by Medicare insert: or our plan] has not approved, you will be responsible for paying
all costs for your participation in the study.
Section 5.2

When you participate in a clinical research study, who pays for
what?

Once you join a Medicare-approved clinical research study, Original Medicare covers the routine
items and services you receive as part of the study, including:
•

Room and board for a hospital stay that Medicare would pay for even if you weren’t in a
study.

•

An operation or other medical procedure if it is part of the research study.

•

Treatment of side effects and complications of the new care.

After Medicare has paid its share of the cost for these services, our plan will pay the difference
between the cost sharing in Original Medicare and your in-network cost sharing as a member of
our plan. This means you will pay the same amount for the services you receive as part of the
study as you would if you received these services from our plan. However, you are required to
submit documentation showing how much cost sharing you paid. Please see Chapter 7 for more
information for submitting requests for payments.

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Chapter 3 Using the plan for your medical services

Here’s an example of how the cost sharing works: Let’s say that you have a lab test that
costs $100 as part of the research study. Let’s also say that your share of the costs for this
test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits.
In this case, Original Medicare would pay $80 for the test, and you would pay the $20
copay required under Original Medicare. You would then notify your plan that you
received a qualified clinical trial service and submit documentation such as a provider bill
to the plan. The plan would then directly pay you $10. Therefore, your net payment is
$10, the same amount you would pay under our plan’s benefits. Please note that in order
to receive payment from your plan, you must submit documentation to your plan such as
a provider bill.
When you are part of a clinical research study, neither Medicare nor our plan will pay for any
of the following:
•

Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.

•

Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your medical condition would normally require only one CT scan.

Do you want to know more?
You can get more information about joining a clinical research study by visiting the Medicare
website to read or download the publication Medicare and Clinical Research Studies. (The
publication is available at: www.medicare.gov/Pubs/pdf/02226-Medicare-and-Clinical-ResearchStudies.pdf.) You can also 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 6

Rules for getting care in a religious non-medical
health care institution

Section 6.1

What is a religious non-medical health care institution?

A religious non-medical health care institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or
a skilled nursing facility is against a member’s religious beliefs, we will instead provide
coverage for care in a religious non-medical health care institution. This benefit is provided only
for Part A inpatient services (non-medical health care services).

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Chapter 3 Using the plan for your medical services

Section 6.2

Receiving Care from a Religious Non-Medical Health Care
Institution

To get care from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical treatment that is non-excepted.
•

Non-excepted medical care or treatment is any medical care or treatment that is
voluntary and not required by any federal, state, or local law.

•

Excepted medical treatment is medical care or treatment that you get that is not voluntary
or is required under federal, state, or local law.

To be covered by our plan, the care you get from a religious non-medical health care institution
must meet the following conditions:
•

The facility providing the care must be certified by Medicare.

•

Our plan’s coverage of services you receive is limited to non-religious aspects of care.

•

If you get services from this institution that are provided to you in a facility, the
following [insert as applicable: conditions apply OR condition applies]:
o You must have a medical condition that would allow you to receive covered services
for inpatient hospital care or skilled nursing facility care.
o [Omit this bullet if not applicable] – and – you must get approval in advance from
our plan before you are admitted to the facility, or your stay will not be covered.

[Plans must explain whether Medicare Inpatient Hospital coverage limits apply (include a
reference to the benefits chart in Chapter 4) or whether there is unlimited coverage for this
benefit.]

SECTION 7

Rules for ownership of durable medical equipment

Section 7.1

Will you own the durable medical equipment after making a
certain number of payments under our plan?

[Plans that allow transfer of ownership of certain DME items to members must modify this
section to explain the conditions under which and when the member can own specified DME.]
Durable medical equipment (DME) includes items such as oxygen equipment and supplies,
wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating
devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the
home. The member always owns certain items, such as prosthetics. In this section, we discuss
other types of DME that you must rent.

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Chapter 3 Using the plan for your medical services

In Original Medicare, people who rent certain types of DME own the equipment after paying
copayments for the item for 13 months. As a member of [insert 2024 plan name], however, you
[insert if the plan sometimes allows ownership: usually] will not acquire ownership of rented
DME items no matter how many copayments you make for the item while a member of our plan,
even if you made up to 12 consecutive payments for the DME item under Original Medicare
before you joined our plan. [Insert if your plan sometimes allows transfer of ownership for items
other than prosthetics: Under certain limited circumstances we will transfer ownership of the
DME item to you. Call member services for more information.]
What happens to payments you made for durable medical equipment if you
switch to Original Medicare?
If you did not acquire ownership of the DME item while in our plan, you will have to make 13
new consecutive payments after you switch to Original Medicare in order to own the item. The
payments made while enrolled in your plan do not count.
Example 1: You made 12 or fewer consecutive payments for the item in Original Medicare and
then joined our plan. The payments you made in Original Medicare do not count. [If your plan
allows ownership insert: You will have to make 13 payments to our plan before owning the
item] [Plans who wish to honor former payments should state so].
Example 2: You made 12 or fewer consecutive payments for the item in Original Medicare and
then joined our plan. You were in our plan but did not obtain ownership while in our plan. You
then go back to Original Medicare. You will have to make 13 consecutive new payments to own
the item once you join Original Medicare again. All previous payments (whether to our plan or
to Original Medicare) do not count.
Section 7.2 Rules for oxygen equipment, supplies, and maintenance
What oxygen benefits are you entitled to?
If you qualify for Medicare oxygen equipment coverage [insert 2024 plan name] will cover:
•

Rental of oxygen equipment

•

Delivery of oxygen and oxygen contents

•

Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents

•

Maintenance and repairs of oxygen equipment

If you leave [insert 2024 plan name] or no longer medically require oxygen equipment, then the
oxygen equipment must be returned.
What happens if you leave your plan and return to Original Medicare?

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Chapter 3 Using the plan for your medical services

Original Medicare requires an oxygen supplier to provide you services for five years. During the
first 36 months you rent the equipment. The remaining 24 months the supplier provides the
equipment and maintenance (you are still responsible for the copayment for oxygen). After five
years you may choose to stay with the same company or go to another company. At this point,
the five-year cycle begins again, even if you remain with the same company, requiring you to
pay copayments for the first 36 months. If you join or leave our plan, the five-year cycle starts
over.

CHAPTER 4:

Medical Benefits Chart
(what is covered and
what you pay)

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

SECTION 1

Understanding your out-of-pocket costs for covered
services

This chapter provides a Medical Benefits Chart that lists your covered services and shows how
much you will pay for each covered service as a member of [insert 2024 plan name]. Later in this
chapter, you can find information about medical services that are not covered. [Insert if
applicable: It also explains limits on certain services.] [If applicable, you may mention other
places where benefits, limitations, and exclusions are described, such as optional additional
benefits, or addenda.]
Section 1.1

Types of out-of-pocket costs you may pay for your covered
services

[Describe all applicable types of cost sharing your plan uses. You may omit those that are not
applicable.]
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.
•

Deductible is the amount you must pay for medical services before our plan begins to
pay its share. [Insert if applicable: (Section 1.2 tells you more about your plan
deductible.)] [Insert if applicable: (Section 1.3 tells you more about your deductibles for
certain categories of services.)]

•

Copayment is the fixed amount you pay each time you receive certain medical services.
You pay a copayment at the time you get the medical service. (The Medical Benefits
Chart in Section 2 tells you more about your copayments.)

•

Coinsurance is the percentage you pay of the total cost of certain medical services. You
pay a coinsurance at the time you get the medical service. (The Medical Benefits Chart in
Section 2 tells you more about your coinsurance.)

Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB)
program should never pay deductibles, copayments, or coinsurance. Be sure to show your proof
of Medicaid or QMB eligibility to your provider, if applicable.
Section 1.2

What is your plan deductible?

[Plans with no deductibles, delete this section and renumber remaining subsections in
Section 1.]
[POS plans with a deductible that applies only to POS services: modify this section as needed.]
Your deductible is [insert deductible amount]. Until you have paid the deductible amount, you
must pay the full cost of your covered services. Once you have paid your deductible, we will
begin to pay our share of the costs for covered medical services and you will pay your share

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

[insert as applicable: (your copayment) OR (your coinsurance amount) OR (your copayment or
coinsurance amount)] for the rest of the calendar year.
[Plans may revise the paragraph to describe the services that are subject to the deductible.] The
deductible does not apply to some services. This means that we will pay our share of the costs
for these services even if you haven’t paid your deductible yet. The deductible does not apply to
the following services:
•

[Insert services not subject to the deductible. Plans must include the $0.00 Medicare
preventative services, emergency/urgently needed services, and insulin furnished through
an item of durable medical equipment.]

Section 1.3

Our plan [insert if plan has an overall deductible described in
Section 1.2: also] has a [insert if plan has an overall deductible
described in Section 1.2: separate] deductible for certain types
of services

[Plans with service category deductibles: insert this section. If applicable, plans may revise the
text as needed to describe how the service category deductible(s) work with the overall plan
deductible.]
[Plans with a service category deductible that is not based on the calendar year – e.g., a per stay
deductible – should revise this section as needed.]
[Insert if plan has an overall deductible described in Section 1.2: In addition to the plan
deductible that applies to all of your covered medical services, we also have a deductible for
certain types of services.]
[Insert if plan does not have an overall deductible and Section 1.2 was therefore omitted: We
have a deductible for certain types of services.]
[[Insert if plan has one service category deductible: The plan has a deductible amount for certain
services. Until you have paid the deductible amount, you must pay the full cost for [insert
service category]. Once you have paid your deductible, we will pay our share of the costs for
these services, and you will pay your share [Insert if applicable: Both the plan deductible and the
deductible for [insert service category] apply to your covered [insert service category]. This
means that once you meet either the plan deductible or the deductible for [insert service
category], we will begin to pay our share of the costs of your covered [insert service category].]]
The benefits chart in Section 2 shows the service category deductibles.
Section 1.4

What is the most you will pay for [insert if applicable: Medicare
Part A and Part B] covered medical services?

[POS plans may revise this information as needed to describe the plan’s MOOP(s).]

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Because you are enrolled in a Medicare Advantage Plan, there is a limit on the total amount you
have to pay out-of-pocket each year for in-network medical services that are covered [insert as
applicable: under Medicare Part A and Part B OR by our plan]. This limit is called the maximum
out-of-pocket (MOOP) amount for medical services. For calendar year 2024 this amount is
[insert MOOP].
The amounts you pay for [insert applicable terms: deductibles, copayments, and coinsurance] for
in-network covered services count toward this maximum out-of-pocket amount. [Plans with no
premium may modify the following sentence as needed] The amounts you pay for your plan
premiums and for your Part D prescription drugs do not count toward your maximum out-ofpocket amount. [Insert if applicable, revising reference to asterisk as needed: In addition,
amounts you pay for some services do not count toward your maximum out-of-pocket amount.
These services are marked with an asterisk in the Medical Benefits Chart.] If you reach the
maximum out-of-pocket amount of [insert MOOP], you will not have to pay any out-of-pocket
costs for the rest of the year for in-network covered [insert if applicable: Part A and Part B]
services. However, you must continue to pay [insert if plan has a premium: your plan premium
and] the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or
another third party).
Section 1.5

Our plan also limits your out-of-pocket costs for certain types
of services

[Plans with service category OOP maximums: insert this section.]
[Plans with a service category OOP maximum that is not based on the calendar year – e.g., a
per stay maximum – should revise this section as needed.]
[In addition to the maximum out-of-pocket amount for covered [insert if applicable: Part A and
Part B] services (see Section 1.4 above), we also have a separate maximum out-of-pocket
amount that applies only to certain types of services.
[Insert if plan has one service category MOOP: The plan has a maximum out-of-pocket amount
of [insert service category MOOP] for [insert service category]. Once you have paid [insert
service category MOOP] out-of-pocket for [insert service category], the plan will cover these
services at no cost to you for the rest of the calendar year. [Insert if service category is included
in MOOP described in Section 1.4: Both the maximum out-of-pocket amount for [insert as
applicable: Part A and Part B OR all covered] medical services and the maximum out-of-pocket
amount for [insert service category] apply to your covered [insert service category]. This means
that once you have paid either [insert MOOP] for [insert as applicable: Part A and Part B OR all
covered] medical services or [insert service category OOP max] for your [insert service
category], the plan will cover your [insert service category] at no cost to you for the rest of the
year.]] The benefits chart in Section 2 shows the service category out-of-pocket maximums.]

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Section 1.6

Our plan does not allow providers to balance bill you

As a member of [insert 2024 plan name], an important protection for you is that [plans with a
plan-level deductible insert: after you meet any deductibles,] you only have to pay your costsharing amount when you get services covered by our plan. Providers may not add additional
separate charges, called balance billing. This protection applies even if we pay the provider less
than the provider charges for a service and even if there is a dispute and we don’t pay certain
provider charges.
Here is how this protection works.
•

If your cost sharing is a copayment (a set amount of dollars, for example, $15.00), then
you pay only that amount for any covered services from a network provider.

•

If your cost sharing is a coinsurance (a percentage of the total charges), then you never
pay more than that percentage. However, your cost depends on which type of provider
you see:
o If you receive the covered services from a network provider, you pay the
coinsurance percentage multiplied by the plan’s reimbursement rate (as
determined in the contract between the provider and the plan).
o If you receive the covered services from an out-of-network provider who
participates with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for participating providers. (Remember, the plan covers
services from out-of-network providers only in certain situations, such as when
you get a referral or for emergencies or urgently needed services.)
o If you receive the covered services from an out-of-network provider who does not
participate with Medicare, you pay the coinsurance percentage multiplied by the
Medicare payment rate for non-participating providers. (Remember, the plan
covers services from out-of-network providers only in certain situations, such as
when you get a referral, or for emergencies or outside the service area for urgently
needed services.)

•

If you believe a provider has balance billed you, call Member Services.

SECTION 2

Use the Medical Benefits Chart to find out what is
covered and how much you will pay

Section 2.1

Your medical benefits and costs as a member of the plan

The Medical Benefits Chart on the following pages lists the services [insert 2024 plan name]
covers and what you pay out-of-pocket for each service. Part D prescription drug coverage is in
Chapter 5. The services listed in the Medical Benefits Chart are covered only when the following
coverage requirements are met:

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

•

Your Medicare covered services must be provided according to the coverage guidelines
established by Medicare.

•

Your services (including medical care, services, supplies, equipment, and Part B
prescription drugs) must be medically necessary. Medically necessary means that the
services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your
medical condition and meet accepted standards of medical practice.

•

[Insert if applicable: You receive your care from a network provider. In most cases, care
you receive from an out-of-network provider will not be covered, unless it is emergent or
urgent care or unless your plan or a network provider has given you a referral. This
means that you will have to pay the provider in full for the services furnished.]

•

[Insert if applicable: You have a primary care provider (a PCP) who is providing and
overseeing your care. [Plans that do not require referrals may omit the rest of this bullet]
In most situations, your PCP must give you approval in advance before you can see other
providers in the plan’s network. This is called giving you a referral.]

•

[Insert if applicable: Some of the services listed in the Medical Benefits Chart are
covered only if your doctor or other network provider gets approval in advance
(sometimes called prior authorization) from us. Covered services that need approval in
advance are marked in the Medical Benefits Chart [insert as appropriate: by an asterisk
OR by a footnote OR in bold OR in italics] [Insert if applicable: In addition, the
following services not listed in the Benefits Chart require prior authorization: [insert
list].]]

•

[Insert as applicable: We may also charge you administrative fees for missed
appointments or for not paying your required cost sharing at the time of service. Call
Member Services if you have questions regarding these administrative fees.]

Other important things to know about our coverage:
•

Like all Medicare health plans, we cover everything that Original Medicare covers. For
some of these benefits, you pay more in our plan than you would in Original Medicare.
For others, you pay less. (If you want to know more about the coverage and costs of
Original Medicare, look in your Medicare & You 2024 handbook. View it online at
www.medicare.gov or ask for a copy 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.)

•

For all preventive services that are covered at no cost under Original Medicare, we also
cover the service at no cost to you. [Insert as applicable: However, if you also are treated
or monitored for an existing medical condition during the visit when you receive the
preventive service, a copayment will apply for the care received for the existing medical
condition.]

•

If Medicare adds coverage for any new services during 2024, either Medicare or our plan
will cover those services.

•

[I-SNPs and C-SNPs, insert: If you are within our plan’s [Insert number 1-6. Plans may
choose any length of time from one to six months for deeming continued eligibility, as
long as they apply the criteria consistently across all members and fully inform members

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

of the policy]-month period of deemed continued eligibility, we will continue to provide
all plan-covered benefits, and your cost-sharing amounts do not change during this
period.]
[Instructions to plans offering MA Uniformity Flexibility benefits:
•

Plans must deliver to each clinically-targeted enrollee a written summary of those
benefits or information in alignment with its different strategy for communicating
information regarding MA Uniformity Flexibility Benefits so that such enrollees are
notified of the MA Uniformity Flexibility benefits for which they are eligible.

•

If applicable, plans must update the Medical Benefits Chart and include a supplemental
benefits chart including a column that details the exact targeted reduced cost-sharing
amount for each specific service, and/or the additional supplemental benefits being
offered.

[Instructions to plans offering Value-Based Insurance Design (VBID) Model benefits:
•

Plans may deliver to each clinically-targeted enrollee a written summary of those
benefits so that such enrollees are notified of VBID benefits for which they are eligible.
For VBID plans that choose to deliver a written notice, VBID plans must follow the VBID
guidance on communications for delivering a written notice when offering targeted
supplemental or VBID benefits. (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).

•

If applicable, plans with VBID should mention reduced cost sharing for their MA
benefits, as well as that members may qualify for a reduction or elimination of their cost
sharing for Part D drugs. Plans with VBID may include the reduction or elimination of
their cost sharing for Part D drugs in Chapter 6, Section 2.1.]

[Insert if offering VBID Model benefits:
Important Benefit Information for Enrollees with Certain Chronic Conditions
•

If you are diagnosed by a plan provider with the following chronic condition(s)
identified below and meet certain medical criteria, you may be eligible for targeted
supplemental benefits and/or reduced cost sharing:
o [List all applicable chronic conditions here.]

o [As applicable, plans offering benefits under VBID that require participation in a
health and wellness program or to see a high-value provider, include those
limitations and then direct the enrollee that they will be provided additional
information with how to take advantage of these additional supplemental benefits.
(See CY 2024 Value-Based Insurance Design Communications and Marketing
Guidelines).]
•

For further detail, please go to the Help with Certain Chronic Conditions row in the
Medical Benefits Chart below.]

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[Insert if offering VBID benefits:
[Plans participating in VBID should use this section to describe the plans strategy for
advance care planning and any other wellness and health care planning (WHP) services that
are being offered:
•
•

Important Benefit Information for all Enrollees Participating in Wellness and Health Care
Planning (WHP) Services
Because [insert 2024 plan name] participates in [insert VBID program name], you will
be eligible for the following WHP services, including advance care planning (ACP)
services:
o [Include a summary of WHP services that are to reach all VBID plan enrollees in
CY 2024. The description must include language that WHP and ACP are
voluntary, and enrollees are free to decline the offers of WHP and ACP.]
o [Include information on how and when the enrollee would be able to access WHP
services.]

[Instructions to plans offering WHP benefits:
•

•

In addition to offering advance care planning as a covered benefit, plans participating
in the VBID Model may deliver to each VBID PBP enrollee a written summary of WHP
benefits so that such enrollees are notified of the benefits for which they are eligible. For
VBID plans that choose to deliver a written notice, VBID plans must follow the VBID
guidance on communications for delivering a written summary when offering WHP
benefits (See CY 2024 Value-Based Insurance Design Communications and Marketing
Guidelines).
If applicable, plans should mention that enrollees may qualify for cost-sharing or copayment reductions].

[Insert if offering VBID flexibility benefits and targeted supplemental benefits to Low Income
Subsidy (LIS) enrollees, as defined in the Plan Communication User Guide (PCUG):
Important Benefit Information for Enrollees Who Qualify for “Extra Help”:
•
•

If you receive “Extra Help” to pay your Medicare prescription drug program costs, such
as premiums, deductibles, and coinsurance, you may be eligible for other targeted
supplemental benefits and/or targeted reduced cost sharing.
Please go to the Medical Benefits Chart in Chapter 4 for further detail.

[Instructions to plans offering VBID benefits for LIS Targeted Enrollees:
•

•

Plans may deliver to each LIS-targeted enrollee a written summary of those benefits so
that such enrollees are notified of VBID benefits for which they are eligible. For VBID
plans that choose to deliver a written notice, VBID plans must follow the VBID guidance
on communications for delivering such a written notice when offering targeted
supplemental or VBID benefits. (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).
Plans who choose to reduce cost sharing for an item or service, including Part D drugs
covered by MA-PD plan through member participation in a plan-sponsored disease
management or similar program, must include a summary of the additional

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

•

supplemental benefits they would receive as well as the activities and/or programs the
member must complete in order to receive the benefit.
If applicable, plans must update the Medical Benefits Chart and include a supplemental
benefits chart including a column that details the exact targeted reduced cost-sharing
amount for each specific service, and/or the additional supplemental benefits being
offered. Specific services should include details as it relates to VBID benefits.
If applicable, plans with VBID should mention that members may qualify for a reduction
or elimination of their cost sharing for Part D drugs in Chapter 6, Section 2.1.]

[Insert only if offering VBID mandatory supplemental benefit flexibility to Cover New and
Existing Technologies or Food and Drug Administration (FDA) approved Medical Devices:
•

Important Benefit Information for VBID Plan Enrollees Eligible to Receive New and
Existing Technologies or FDA Approved Medical Devices.

•

Because [insert 2024 plan name] participates in [insert VBID program name], you may
be eligible to receive new and existing technologies or FDA approved Medical Devices:
o [Include a description of the new and existing technologies or FDA approved
medical devices specifying eligibility for the benefit and associated cost sharing
as an enrollee in the VBID plan in 2024. The description must include language
that enrollees are free to decline the benefit and how they would notify the plan of
declining this supplemental benefit.]

[Instructions to plans offering Coverage of New and Existing Technologies or FDA approved
Medical Devices as a mandatory supplemental benefit:
•

Plans may deliver to each VBID PBP’s enrollee a written summary of coverage of new
and existing technologies or FDA approved medical devices so that such enrollees are
notified of the benefits for which they are eligible. For VBID plans that choose to deliver
a written notice, VBID plans must follow the VBID guidance on communications for
delivering a written summary when offering coverage of new and existing technologies or
FDA approved medical devices (See CY 2024 Value-Based Insurance Design
Communications and Marketing Guidelines).]

[Insert if offering Special Supplemental Benefits for the Chronically Ill: Important Benefit
Information for Enrollees with Chronic Conditions
•

If you are diagnosed with the following chronic condition(s) identified below and meet
certain criteria, you may be eligible for special supplemental benefits for the chronically
ill.
o [List all applicable chronic conditions here.]

o [Include information regarding the process and/or criteria for determining
eligibility for special supplemental benefits for the chronically ill]
•

Please go to the Special Supplemental Benefits for the Chronically Ill row in the below
Medical Benefits Chart for further detail.

•

Please contact us to find out exactly which benefits you may be eligible for.

You will see this apple next to the preventive services in the benefits chart.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

[Instructions on completing benefits chart:
•

When preparing this Benefits Chart, please refer to the instructions for completing the
standardized ANOC and EOC.

•

If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must
insert the 2023 Medicare amounts and must insert: These are 2023 cost-sharing amounts
and may change for 2024. [Insert plan name] will provide updated rates as soon as they
are released. Member cost-sharing amounts may not be left blank.

•

For all preventive care and screening test benefit information, plans that cover a richer
benefit than Original Medicare do not need to include given description (unless still
applicable) and may instead describe plan benefit.

•

Optional supplemental benefits are not permitted within the chart; plans may describe
these benefits within Section 2.2.

•

Plans with out of network services must clearly indicate for each service, both the in
network and out of network cost sharing.

•

Plans that have tiered cost sharing of medical benefits based on contracted providers
should clearly indicate for each service the cost sharing for each tier, in addition to
defining what each tier means and how it corresponds to the special characters and/or
footnotes indicating such in the provider directory (When one reads the provider
directory, it is clear what the special character and/or footnote means when reading this
section of the EOC. Refer to the current Medicare Advantage and Section 1876 Cost Plan
Provider Directory Model for more information.).

•

Plans with a POS benefit may include POS information within the benefits chart or may
include a section following the chart listing POS-eligible benefits and cost sharing.

•

Plans should clearly indicate which benefits are subject to PA (plans may use asterisks or
similar method).

•

Plans may insert any additional benefits information based on the plan’s approved bid
that is not captured in the benefits chart or in the exclusions section. Additional benefits
should be placed alphabetically in the chart.

•

Plans must describe any restrictive policies, limitations, or monetary limits that might
impact a member’s access to services within the chart.

•

Plans may add references to the list of exclusions in Section 3.1 as appropriate.

•

Plans must make it clear for members (in the sections where member cost sharing is
shown) whether their hospital copays or coinsurance apply on the date of admission
and/or on the date of discharge.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Medical Benefits Chart
Services that are covered for you

What you must pay when
you get these services

Abdominal aortic aneurysm screening
A one-time screening ultrasound for people at risk. The plan
only covers this screening if you have certain risk factors and if
you get a referral for it from your physician, physician assistant,
nurse practitioner, or clinical nurse specialist. [Also list any
additional benefits offered.]

There is no coinsurance,
copayment, or deductible
for members eligible for
this preventive screening.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Acupuncture for chronic low back pain
Covered services include:
Up to 12 visits in 90 days are covered for Medicare beneficiaries
under the following circumstances:
For the purpose of this benefit, chronic low back pain is defined
as:
•

Lasting 12 weeks or longer;

•

nonspecific, in that it has no identifiable systemic cause
(i.e., not associated with metastatic, inflammatory,
infectious disease, etc.);

•

not associated with surgery; and

• not associated with pregnancy.
An additional eight sessions will be covered for those patients
demonstrating an improvement. No more than 20 acupuncture
treatments may be administered annually.
Treatment must be discontinued if the patient is not improving
or is regressing.
Provider Requirements:
Physicians (as defined in 1861(r)(1) of the Social Security Act
(the Act)) may furnish acupuncture in accordance with
applicable state requirements.
Physician assistants (PAs), nurse practitioners (NPs)/clinical
nurse specialists (CNSs) (as identified in 1861(aa) (5) of the
Act), and auxiliary personnel may furnish acupuncture if they
meet all applicable state requirements and have:
• a masters or doctoral level degree in acupuncture or
Oriental Medicine from a school accredited by the
Accreditation Commission on Acupuncture and Oriental
Medicine (ACAOM); and,
• a current, full, active, and unrestricted license to practice
acupuncture in a State, Territory, or Commonwealth (i.e.,
Puerto Rico) of the United States, or District of
Columbia.
Auxiliary personnel furnishing acupuncture must be under the
appropriate level of supervision of a physician, PA, or NP/CNS
required by our regulations at 42 CFR §§ 410.26 and 410.27.
[Also list any additional benefits offered.]

What you must pay when
you get these services
[List copays / coinsurance
/ deductible.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

Ambulance services
•

•

Covered ambulance services include fixed wing, rotary
wing, and ground ambulance services, to the nearest
appropriate facility that can provide care if they are
furnished to a member whose medical condition is such that
other means of transportation could endanger the person’s
health or if authorized by the plan.
Non-emergency transportation by ambulance is appropriate
if it is documented that the member’s condition is such that
other means of transportation could endanger the person’s
health and that transportation by ambulance is medically
required.
Annual wellness visit

If you’ve had Part B for longer than 12 months, you can get an
annual wellness visit to develop or update a personalized
prevention plan based on your current health and risk factors.
This is covered once every 12 months.
Note: Your first annual wellness visit can’t take place within 12
months of your Welcome to Medicare preventive visit.
However, you don’t need to have had a Welcome to Medicare
visit to be covered for annual wellness visits after you’ve had
Part B for 12 months.
Bone mass measurement
For qualified individuals (generally, this means people at risk of
losing bone mass or at risk of osteoporosis), the following
services are covered every 24 months or more frequently if
medically necessary: procedures to identify bone mass, detect
bone loss, or determine bone quality, including a physician’s
interpretation of the results.
[Also list any additional benefits offered.]

[List copays/coinsurance/
deductible. Specify whether
cost sharing applies oneway or for round trips.]

There is no coinsurance,
copayment, or deductible
for the annual wellness
visit.

There is no coinsurance,
copayment, or deductible
for Medicare-covered bone
mass measurement.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Breast cancer screening (mammograms)
Covered services include:
One baseline mammogram between the ages of 35 and 39
One screening mammogram every 12 months for women
aged 40 and older
• Clinical breast exams once every 24 months
[Also list any additional benefits offered.]
•
•

Cardiac rehabilitation services
Comprehensive programs of cardiac rehabilitation services that
include exercise, education, and counseling are covered for
members who meet certain conditions with a doctor’s [insert as
appropriate: referral OR order]. The plan also covers intensive
cardiac rehabilitation programs that are typically more rigorous
or more intense than cardiac rehabilitation programs.
[Also list any additional benefits offered.]
Cardiovascular disease risk reduction visit (therapy for
cardiovascular disease)
We cover one visit per year with your primary care doctor to
help lower your risk for cardiovascular disease. During this visit,
your doctor may discuss aspirin use (if appropriate), check your
blood pressure, and give you tips to make sure you’re eating
healthy.
[Also list any additional benefits offered.]
Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of cardiovascular
disease) once every 5 years (60 months).
[Also list any additional benefits offered.]

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible
for covered screening
mammograms.

[List copays/coinsurance/
deductible]

There is no coinsurance,
copayment, or deductible
for the intensive behavioral
therapy cardiovascular
disease preventive benefit.

There is no coinsurance,
copayment, or deductible
for cardiovascular disease
testing that is covered once
every 5 years.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Cervical and vaginal cancer screening
Covered services include:
For all women: Pap tests and pelvic exams are covered once
every 24 months
• If you are at high risk of cervical or vaginal cancer or you
are of childbearing age and have had an abnormal Pap test
within the past 3 years: one Pap test every 12 months
[Also list any additional benefits offered.]
•

Chiropractic services
Covered services include:
[If the plan only covers manual manipulation, insert: We
cover only] Manual manipulation of the spine to correct
subluxation
[Also list any additional benefits offered.]
•

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible
for Medicare-covered
preventive Pap and pelvic
exams.

[List copays / coinsurance
/ deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Colorectal cancer screening
The following screening tests are covered:
•

•

•
•
•
•

•

Colonoscopy has no minimum or maximum age
limitation and is covered once every 120 months (10
years) for patients not at high risk, or 48 months after a
previous flexible sigmoidoscopy for patients who are not
at high risk for colorectal cancer, and once every 24
months for high risk patients after a previous screening
colonoscopy or barium enema.
Flexible sigmoidoscopy for patients 45 years and older.
Once every 120 months for patients not at high risk after
the patient received a screening colonoscopy. Once every
48 months for high risk patients from the last flexible
sigmoidoscopy or barium enema.
Screening fecal-occult blood tests for patients 45 years
and older. Once every 12 months.
Multitarget stool DNA for patients 45 to 85 years of age
and not meeting high risk criteria. Once every 3 years.
Blood-based Biomarker Tests for patients 45 to 85 years
of age and not meeting high risk criteria. Once every 3
years.
Barium Enema as an alternative to colonoscopy for
patients at high risk and 24 months since the last
screening barium enema or the last screening
colonoscopy.
Barium Enema as an alternative to flexible
sigmoidoscopy for patient not at high risk and 45 years
or older. Once at least 48 months following the last
screening barium enema or screening flexible
sigmoidoscopy.

As of January 1, 2023, colorectal cancer screening tests include
a follow-on screening colonoscopy after a Medicare covered
non-invasive stool-based colorectal cancer screening test returns
a positive result.
[Also list any additional benefits offered.]

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible
for a Medicare-covered
colorectal cancer
screening exam, excluding
barium enemas, for which
coinsurance applies. If
your doctor finds and
removes a polyp or other
tissue during the
colonoscopy or flexible
sigmoidoscopy, the
screening exam becomes a
diagnostic exam and you
pay 15% of the Medicareapproved amount for your
doctors’ services. In a
hospital outpatient setting,
you also pay the hospital a
15% coinsurance. The
Part B deductible doesn’t
apply. [If applicable, list
copayment and/or
coinsurance charged for
barium enema.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
[Include row if applicable. If plan offers dental benefits as
optional supplemental benefits, they should not be included in
the chart. Plans may describe them in Section 2.2 instead.]
Dental services
In general, preventive dental services (such as cleaning, routine
dental exams, and dental x-rays) are not covered by Original
Medicare. We cover:
[List any additional benefits offered, such as routine dental
care.]

What you must pay when
you get these services
[List copays / coinsurance
/ deductible]

Depression screening
We cover one screening for depression per year. The screening
must be done in a primary care setting that can provide followup treatment and/or referrals.
[Also list any additional benefits offered.]
Diabetes screening
We cover this screening (includes fasting glucose tests) if you
have any of the following risk factors: high blood pressure
(hypertension), history of abnormal cholesterol and triglyceride
levels (dyslipidemia), obesity, or a history of high blood sugar
(glucose). Tests may also be covered if you meet other
requirements, like being overweight and having a family history
of diabetes.
Based on the results of these tests, you may be eligible for up to
two diabetes screenings every 12 months.
[Also list any additional benefits offered.]

There is no coinsurance,
copayment, or deductible
for an annual depression
screening visit.

There is no coinsurance,
copayment, or deductible
for the Medicare covered
diabetes screening tests.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

Diabetes self-management training, diabetic services, and
supplies
[Plans may put items listed under a single bullet in separate
bullets if the plan charges different copays. However, all items
in the bullets must be included.] For all people who have
diabetes (insulin and non-insulin users). Covered services
include:

[List copays / coinsurance
/ deductible]

Supplies to monitor your blood glucose: Blood glucose
monitor, blood glucose test strips, lancet devices and
lancets, and glucose-control solutions for checking the
accuracy of test strips and monitors.
• For people with diabetes who have severe diabetic foot
disease: One pair per calendar year of therapeutic custommolded shoes (including inserts provided with such shoes)
and two additional pairs of inserts, or one pair of depth
shoes and three pairs of inserts (not including the noncustomized removable inserts provided with such shoes).
Coverage includes fitting.
• Diabetes self-management training is covered under certain
conditions.
[Also list any additional benefits offered.]
•

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Durable medical equipment (DME) and related supplies
(For a definition of durable medical equipment, see Chapter 12
as well as Chapter 3, Section 7 of this document.)
Covered items include, but are not limited to: wheelchairs,
crutches, powered mattress systems, diabetic supplies, hospital
beds ordered by a provider for use in the home, IV infusion
pumps, speech generating devices, oxygen equipment,
nebulizers, and walkers.
[Plans that do not limit the DME brands and manufacturers that
you will cover insert: We cover all medically necessary DME
covered by Original Medicare. If our supplier in your area does
not carry a particular brand or manufacturer, you may ask them
if they can special order it for you. [Insert as applicable: We
included a copy of our DME supplier directory in the envelope
with this document.] The most recent list of suppliers is [insert
as applicable: also] available on our website at [insert URL].]
[Plans that limit the DME brands and manufacturers that you
will cover insert: With this Evidence of Coverage document, we
sent you [insert 2024 plan name]’s list of DME. The list tells
you the brands and manufacturers of DME that we will cover.
[Insert as applicable: We included a copy of our DME supplier
directory in the envelope with this document]. This most recent
list of brands, manufacturers, and suppliers is also available on
our website at [insert URL].
Generally, [insert 2024 plan name] covers any DME covered by
Original Medicare from the brands and manufacturers on this
list. We will not cover other brands and manufacturers unless
your doctor or other provider tells us that the brand is
appropriate for your medical needs. However, if you are new to
[insert 2024 plan name] and are using a brand of DME that is
not on our list, we will continue to cover this brand for you for
up to 90 days. During this time, you should talk with your doctor
to decide what brand is medically appropriate for you after this
90-day period. (If you disagree with your doctor, you can ask
him or her to refer you for a second opinion.)
If you (or your provider) don’t agree with the plan’s coverage
decision, you or your provider may file an appeal. You can also
file an appeal if you don’t agree with your provider’s decision
about what product or brand is appropriate for your medical
condition. (For more information about appeals, see Chapter 9,
What to do if you have a problem or complaint (coverage
decisions, appeals, complaints).)]

What you must pay when
you get these services
[List copays/coinsurance/
deductible]
Your cost sharing for
Medicare oxygen
equipment coverage
is [Insert copay amount or
coinsurance percentage],
every [Insert required
frequency of payment].
[Plans that use a constant
cost-sharing structure for
oxygen equipment insert:
Your cost sharing will not
change after being enrolled
for 36 months.]
[Plans that wish to vary
cost sharing for oxygen
equipment after 36 months
insert details including
whether original cost
sharing resumes after 5
years and you are still in
the plan.] [If cost sharing
is different for members
who made 36 months of
rental payments prior to
joining the plan insert:
If prior to enrolling in
[insert 2024 plan name]
you had made 36 months
of rental payment for
oxygen equipment
coverage, your cost sharing
in [insert 2024 plan name]
is [Plans should insert cost
sharing].]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Emergency care
Emergency care refers to services that are:
Furnished by a provider qualified to furnish emergency
services, and
• Needed to evaluate or stabilize an emergency medical
condition.
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 (and, if you are a
pregnant woman, loss of an unborn child), 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.
Cost sharing for necessary emergency services furnished out-ofnetwork is the same as for such services furnished in-network.
•

[Also identify whether this coverage is only covered within the
U.S. as required or whether emergency care is also available as
a supplemental benefit that provides world-wide
emergency/urgent coverage.]

What you must pay when
you get these services
[List copays / coinsurance.
If applicable, explain that
cost sharing is waived if
member is admitted to
hospital.]
[Insert if applicable: If you
receive emergency care at
an out-of-network hospital
and need inpatient care
after your emergency
condition is stabilized,
[Insert one or both: you
must return to a network
hospital in order for your
care to continue to be
covered OR you must have
your inpatient care at the
out-of-network hospital
authorized by the plan and
your cost is the [insert if
applicable: highest] cost
sharing you would pay at a
network hospital.]

Health and wellness education programs

[List copays / coinsurance
[These are programs focused on health conditions such as high
blood pressure, cholesterol, asthma, and special diets. Programs / deductible]
designed to enrich the health and lifestyles of members include
weight management, fitness, and stress management. Describe
the nature of the programs here.
If this benefit is not applicable, plans should delete this row.]
Hearing services
Diagnostic hearing and balance evaluations performed by your
[insert as applicable: PCP OR provider] to determine if you
need medical treatment are covered as outpatient care when
furnished by a physician, audiologist, or other qualified
provider.
[List any additional benefits offered, such as routine hearing
exams, hearing aids, and evaluations for fitting hearing aids.]

[List copays / coinsurance
/ deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Help with Certain Chronic Conditions
[If the enrollee has been diagnosed by a plan provider with the
certain chronic condition(s) identified and meets certain
criteria, they may be eligible for other targeted supplemental
benefits and/or targeted reduced cost sharing. The certain
chronic conditions must be listed here. The benefits listed here
must be approved in the bid. Describe the nature of the benefits
here.
If this benefit is not applicable, plans should delete this entire
row.]
HIV screening
For people who ask for an HIV screening test or who are at
increased risk for HIV infection, we cover:
• One screening exam every 12 months
For women who are pregnant, we cover:
•

What you must pay when
you get these services
[List copays / coinsurance
/ deductible]

There is no coinsurance,
copayment, or deductible
for members eligible for
Medicare-covered
preventive HIV screening.

Up to three screening exams during a pregnancy

[Also list any additional benefits offered.]
Home health agency care
[If needed, plans may revise language related to the doctor
certification requirement.] Prior to receiving home health
services, a doctor must certify that you need home health
services and will order home health services to be provided by a
home health agency. You must be homebound, which means
leaving home is a major effort.
Covered services include, but are not limited to:
•

•
•
•

Part-time or intermittent skilled nursing and home health
aide services (to be covered under the home health care
benefit, your skilled nursing and home health aide services
combined must total fewer than 8 hours per day and 35
hours per week)
Physical therapy, occupational therapy, and speech therapy
Medical and social services
Medical equipment and supplies

[List copays / coinsurance
/ deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Home infusion therapy
Home infusion therapy involves the intravenous or subcutaneous
administration of drugs or biologicals to an individual at home.
The components needed to perform home infusion include the
drug (for example, antivirals, immune globulin), equipment (for
example, a pump), and supplies (for example, tubing and
catheters).
Covered services include, but are not limited to:
Professional services, including nursing services, furnished
in accordance with the plan of care
• Patient training and education not otherwise covered under
the durable medical equipment benefit
• Remote monitoring
• Monitoring services for the provision of home infusion
therapy and home infusion drugs furnished by a qualified
home infusion therapy supplier
[Also list any additional benefits offered.]
•

What you must pay when
you get these services
[List copays / coinsurance
/ deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Hospice care
You are eligible for the hospice benefit when your doctor and
the hospice medical director have given you a terminal
prognosis certifying that you’re terminally ill and have 6 months
or less to live if your illness runs its normal course. You may
receive care from any Medicare-certified hospice program. Your
plan is obligated to help you find Medicare-certified hospice
programs in the plan’s service area, including those the MA
organization owns, controls, or has a financial interest in. Your
hospice doctor can be a network provider or an out-of-network
provider.
Covered services include:
• Drugs for symptom control and pain relief
• Short-term respite care
• Home care
When you are admitted to a hospice you have the right to remain
in your plan; if you chose to remain in your plan you must
continue to pay plan premiums.
For hospice services and for services that are covered by
Medicare Part A or B and are related to your terminal prognosis:
Original Medicare (rather than our plan) will pay your hospice
provider for your hospice services and any Part A and Part B
services related to your terminal prognosis. While you are in the
hospice program, your hospice provider will bill Original
Medicare for the services that Original Medicare pays for. You
will be billed Original Medicare cost sharing.
For services that are covered by Medicare Part A or B and are
not related to your terminal prognosis: If you need nonemergency, non-urgently needed services that are covered under
Medicare Part A or B and that are not related to your terminal
prognosis, your cost for these services depends on whether you
use a provider in our plan’s network and follow plan rules (such
as if there is a requirement to obtain prior authorization).
•
•

If you obtain the covered services from a network provider
and follow plan rules for obtaining service, you only pay
the plan cost-sharing amount for in-network services
If you obtain the covered services from an out-of-network
provider, you pay the cost sharing under Fee-for-Service
Medicare (Original Medicare)

What you must pay when
you get these services
When you enroll in a
Medicare-certified hospice
program, your hospice
services and your Part A
and Part B services related
to your terminal prognosis
are paid for by Original
Medicare, not [insert 2024
plan name].
[Include information about
cost sharing for hospice
consultation services if
applicable.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

Hospice care (continued)
For services that are covered by [insert 2024 plan name] but are
not covered by Medicare Part A or B: [insert 2024 plan name]
will continue to cover plan-covered services that are not covered
under Part A or B whether or not they are related to your
terminal prognosis. You pay your plan cost-sharing amount for
these services.
For drugs that may be covered by the plan’s Part D benefit: If
these drugs are unrelated to your terminal hospice condition you
pay cost sharing. If they are related to your terminal hospice
condition, then you pay Original Medicare cost sharing. Drugs
are never covered by both hospice and our plan at the same time.
For more information, please see Chapter 5, Section 9.4 (What if
you’re in Medicare-certified hospice).
Note: If you need non-hospice care (care that is not related to
your terminal prognosis), you should contact us to arrange the
services.
[Insert if applicable, edit as appropriate: Our plan covers
hospice consultation services (one time only) for a terminally ill
person who hasn’t elected the hospice benefit.]
Immunizations
Covered Medicare Part B services include:
Pneumonia vaccine
Flu shots, once each flu season in the fall and winter, with
additional flu shots if medically necessary
• Hepatitis B vaccine if you are at high or intermediate risk of
getting Hepatitis B
• COVID-19 vaccine
• Other vaccines if you are at risk and they meet Medicare
Part B coverage rules
We also cover some vaccines under our Part D prescription drug
benefit.
[Also list any additional benefits offered.]
•
•

There is no coinsurance,
copayment, or deductible
for the pneumonia,
influenza, Hepatitis B, and
COVID-19 vaccines.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Inpatient hospital care
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.
[List days covered and any restrictions that apply.] Covered
services include but are not limited to:
•
•
•
•
•
•
•
•
•
•
•
•

Semi-private room (or a private room if medically
necessary)
Meals including special diets
Regular nursing services
Costs of special care units (such as intensive care or
coronary care units)
Drugs and medications
Lab tests
X-rays and other radiology services
Necessary surgical and medical supplies
Use of appliances, such as wheelchairs
Operating and recovery room costs
Physical, occupational, and speech language therapy
Inpatient substance abuse services

What you must pay when
you get these services
[List all cost sharing
(deductible, copayments/
coinsurance / deductible)
and the period for which
they will be charged. If
cost sharing is based on
the Original Medicare or a
plan-defined benefit
period, include definition/
explanation of approved
benefit period here. Plans
that use per-admission
deductible include: A per
admission deductible is
applied once during the
defined benefit period. [In
addition, if applicable,
explain all other cost
sharing that is charged
during a benefit period.]]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

Inpatient hospital care (continued)
Under certain conditions, the following types of transplants
are covered: corneal, kidney, kidney-pancreatic, heart, liver,
lung, heart/lung, bone marrow, stem cell, and
intestinal/multivisceral. If you need a transplant, we will
arrange to have your case reviewed by a Medicare-approved
transplant center that will decide whether you are a
candidate for a transplant [Plans with a provider network
insert: Transplant providers may be local or outside of the
service area. If our in-network transplant services are
outside the community pattern of care, you may choose to
go locally as long as the local transplant providers are
willing to accept the Original Medicare rate. If [insert 2024
plan name] provides transplant services at a location
outside the pattern of care for transplants in your
community and you choose to obtain transplants at this
distant location, we will arrange or pay for appropriate
lodging and transportation costs for you and a companion.]
[Plans may further define the specifics of transplant travel
coverage.]
• Blood - including storage and administration. Coverage of
whole blood and packed red cells begins only with the
fourth pint of blood that you need - you must either pay the
costs for the first 3 pints of blood you get in a calendar year
or have the blood donated by you or someone else. All other
components of blood are covered beginning with the first
pint used. [Modify as necessary if the plan begins coverage
with an earlier pint.]
• Physician services
Note: To be an inpatient, your provider must write an order to
admit you formally as an inpatient of the hospital. Even if you
stay in the hospital overnight, you might still be considered an
outpatient. If you are not sure if you are an inpatient or an
outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called Are You a Hospital Inpatient or Outpatient? If You Have
Medicare – Ask! This fact sheet is available on the Web at
https://www.medicare.gov/sites/default/files/2021-10/11435Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1800-633-4227). TTY users call 1-877-486-2048. You can call
these numbers for free, 24 hours a day, 7 days a week.
•

[If cost sharing is not
based on the Original
Medicare or plan-defined
benefit period, explain
here when the cost sharing
will be applied. If it is
charged on a per
admission basis, include as
applicable: A deductible
and/or other cost sharing is
charged for each inpatient
stay.]
[If inpatient cost sharing
varies based on hospital
tier, enter that cost sharing
in the data entry fields.]
If you get [insert if
applicable: authorized]
inpatient care at an out-ofnetwork hospital after your
emergency condition is
stabilized, your cost is the
[Insert if applicable:
highest] cost sharing you
would pay at a network
hospital.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Inpatient services in a psychiatric hospital
Covered services include mental health care services that require
a hospital stay. [List days covered, restrictions such as 190-day
lifetime limit for inpatient services in a psychiatric hospital. The
190-day limit does not apply to inpatient mental health services
provided in a psychiatric unit of a general hospital.]

What you must pay when
you get these services

[List all cost sharing
(deductible, copayments/
coinsurance / deductible)
and the period for which
they will be charged. If
cost sharing is based on
the Original Medicare or a
plan-defined benefit
period, include definition/
explanation of approved
benefit period here. Plans
that use per-admission
deductible include: A per
admission deductible is
applied once during the
defined benefit period. [In
addition, if applicable,
explain all other cost
sharing that is charged
during a benefit period.]]
[If cost sharing is not
based on the Original
Medicare or plan-defined
benefit period, explain
here when the cost
sharing will be applied. If
it is charged on a per
admission basis, include
as applicable: A
deductible and/or other
cost sharing is charged
for each inpatient stay.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Inpatient stay: Covered services received in a hospital or
SNF during a non-covered inpatient stay
[Plans with no day limitations on a plan’s hospital or SNF
coverage may modify or delete this row as appropriate.]
If you have exhausted your inpatient benefits or if the inpatient
stay is not reasonable and necessary, we will not cover your
inpatient stay. However, in some cases, we will cover certain
services you receive while you are in the hospital or the skilled
nursing facility (SNF). Covered services include, but are not
limited to:
•
•
•
•
•
•

•

Physician services
Diagnostic tests (like lab tests)
X-ray, radium, and isotope therapy including technician
materials and services
Surgical dressings
Splints, casts, and other devices used to reduce fractures
and dislocations
Prosthetics and orthotics devices (other than dental) that
replace all or part of an internal body organ (including
contiguous tissue), or all or part of the function of a
permanently inoperative or malfunctioning internal body
organ, including replacement or repairs of such devices
Leg, arm, back, and neck braces; trusses, and artificial legs,
arms, and eyes including adjustments, repairs, and
replacements required because of breakage, wear, loss, or a
change in the patient’s physical condition
Physical therapy, speech therapy, and occupational therapy

What you must pay when
you get these services
[List copays / coinsurance
/ deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Medical nutrition therapy
This benefit is for people with diabetes, renal (kidney) disease
(but not on dialysis), or after a kidney transplant when [insert as
appropriate: referred OR ordered] by your doctor.
We cover 3 hours of one-on-one counseling services during your
first year that you receive medical nutrition therapy services
under Medicare (this includes our plan, any other Medicare
Advantage plan, or Original Medicare), and 2 hours each year
after that. If your condition, treatment, or diagnosis changes, you
may be able to receive more hours of treatment with a
physician’s [insert as appropriate: referral OR order]. A
physician must prescribe these services and renew their [insert
as appropriate: referral OR order] yearly if your treatment is
needed into the next calendar year.
[Also list any additional benefits offered.]
Medicare Diabetes Prevention Program (MDPP)
MDPP services will be covered for eligible Medicare
beneficiaries under all Medicare health plans.
MDPP is a structured health behavior change intervention that
provides practical training in long-term dietary change,
increased physical activity, and problem-solving strategies for
overcoming challenges to sustaining weight loss and a healthy
lifestyle.

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible
for members eligible for
Medicare-covered medical
nutrition therapy services.

There is no coinsurance,
copayment, or deductible
for the MDPP benefit.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Medicare Part B prescription drugs
[MA plans that will be or expect to use Part B step therapy
should include the Part B drug categories below that may or will
be subject to Part B step therapy as well as a link to a list of
drugs that will be subject to Part B step therapy. The link may
be updated throughout the year and any changes need to be
added at least 30 days prior to implementation per 42 CFR
42.111(d)]
These drugs are covered under Part B of Original Medicare.
Members of our plan receive coverage for these drugs through
our plan. Covered drugs include:

What you must pay when
you get these services

[List copays / coinsurance
/ deductible] [If applicable
(plan has a coinsurance
for Part B drugs): Indicate
that certain rebatable
drugs may be subject to a
lower coinsurance]
[Indicate whether drugs
may be subject to step
therapy] [Indicate insulin
cost sharing is subject to a
coinsurance cap of $35 for
one-month’s supply of
insulin, and specify service
category or plan level
deductibles do not apply.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Medicare Part B prescription drugs (continued)
Drugs that usually aren’t self-administered by the patient
and are injected or infused while you are getting physician,
hospital outpatient, or ambulatory surgical center services
• Insulin furnished through an item of durable medical
equipment (such as a medically necessary insulin pump)
• Other drugs you take using durable medical equipment
(such as nebulizers) that were authorized by the plan
• Clotting factors you give yourself by injection if you have
hemophilia
• Immunosuppressive Drugs, if you were enrolled in
Medicare Part A at the time of the organ transplant
• Injectable osteoporosis drugs, if you are homebound, have a
bone fracture that a doctor certifies was related to postmenopausal osteoporosis, and cannot self-administer the
drug
• Antigens
• Certain oral anti-cancer drugs and anti-nausea drugs
• Certain drugs for home dialysis, including heparin, the
antidote for heparin when medically necessary, topical
anesthetics, and erythropoiesis-stimulating agents [plans
may delete any of the following drugs that are not covered
under the plan] (such as Epogen, Procrit, Epoetin Alfa,
Aranesp, or Darbepoetin Alfa)
• Intravenous Immune Globulin for the home treatment of
primary immune deficiency diseases
[insert if applicable: The following link will take you to a list of
Part B Drugs that may be subject to Step Therapy: insert link]
We also cover some vaccines under our Part B and Part D
prescription drug benefit.
Chapter 5 explains the Part D prescription drug benefit,
including rules you must follow to have prescriptions covered.
What you pay for your Part D prescription drugs through our
plan is explained in Chapter 6.
•

What you must pay when
you get these services

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Obesity screening and therapy to promote sustained
weight loss
If you have a body mass index of 30 or more, we cover intensive
counseling to help you lose weight. This counseling is covered if
you get it in a primary care setting, where it can be coordinated
with your comprehensive prevention plan. Talk to your primary
care doctor or practitioner to find out more.
[Also list any additional benefits offered.]
Opioid treatment program services
Members of our plan with opioid use disorder (OUD) can
receive coverage of services to treat OUD through an Opioid
Treatment Program (OTP) which includes the following
services:
U.S. Food and Drug Administration (FDA)-approved opioid
agonist and antagonist medication-assisted treatment
(MAT) medications.
• Dispensing and administration of MAT medications (if
applicable)
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments
[Plans can include other covered items and services as
appropriate (not to include meals and transportation).]
•

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible
for preventive obesity
screening and therapy.

[List copays / coinsurance
/ deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you

What you must pay when
you get these services

Outpatient diagnostic tests and therapeutic services and
supplies
Covered services include, but are not limited to:

[List copays / coinsurance
/ deductible]

•
•

•
•
•
•

•

X-rays
Radiation (radium and isotope) therapy including technician
materials and supplies [List separately any services for
which a separate copay/coinsurance applies over and
above the outpatient radiation therapy copay/coinsurance.]
Surgical supplies, such as dressings
Splints, casts, and other devices used to reduce fractures
and dislocations
Laboratory tests
Blood - including storage and administration. Coverage of
whole blood and packed red cells begins only with the
fourth pint of blood that you need - you must either pay the
costs for the first 3 pints of blood you get in a calendar year
or have the blood donated by you or someone else. All other
components of blood are covered beginning with the first
pint used [Modify as necessary if the plan begins coverage
with an earlier pint.]
Other outpatient diagnostic tests [Plans can include other
covered tests as appropriate.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Outpatient hospital observation
Observation services are hospital outpatient services given to
determine if you need to be admitted as an inpatient or can be
discharged.
For outpatient hospital observation services to be covered,
they must meet the Medicare criteria and be considered
reasonable and necessary. Observation services are covered
only when provided by the order of a physician or another
individual authorized by state licensure law and hospital staff
bylaws to admit patients to the hospital or order outpatient
tests.
Note: Unless the provider has written an order to admit you as
an inpatient to the hospital, you are an outpatient and pay the
cost-sharing amounts for outpatient hospital services. Even if
you stay in the hospital overnight, you might still be
considered an outpatient. If you are not sure if you are an
outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called Are You a Hospital Inpatient or Outpatient? If You
Have Medicare – Ask! This fact sheet is available on the Web
at https://www.medicare.gov/sites/default/files/202110/11435-Inpatient-or-Outpatient.pdf or by calling 1-800MEDICARE (1-800-633-4227). TTY users call 1-877-4862048. You can call these numbers for free, 24 hours a day, 7
days a week.

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Outpatient hospital services
We cover medically-necessary services you get in the
outpatient department of a hospital for diagnosis or treatment
of an illness or injury.
Covered services include, but are not limited to:

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

Services in an emergency department or outpatient clinic,
such as observation services or outpatient surgery
• Laboratory and diagnostic tests billed by the hospital
• Mental health care, including care in a partialhospitalization program, if a doctor certifies that inpatient
treatment would be required without it
• X-rays and other radiology services billed by the hospital
• Medical supplies such as splints and casts
• Certain drugs and biologicals that you can’t give yourself
Note: Unless the provider has written an order to admit you as
an inpatient to the hospital, you are an outpatient and pay the
cost-sharing amounts for outpatient hospital services. Even if
you stay in the hospital overnight, you might still be
considered an outpatient. If you are not sure if you are an
outpatient, you should ask the hospital staff.
You can also find more information in a Medicare fact sheet
called Are You a Hospital Inpatient or Outpatient? If You
Have Medicare – Ask! This fact sheet is available on the Web
at https://www.medicare.gov/sites/default/files/202110/11435-Inpatient-or-Outpatient.pdf or by calling 1-800MEDICARE (1-800-633-4227). TTY users call 1-877-4862048. You can call these numbers for free, 24 hours a day, 7
days a week.
[Also list any additional benefits offered.]
•

Outpatient mental health care
Covered services include:
Mental health services provided by a state-licensed
psychiatrist or doctor, clinical psychologist, clinical social
worker, clinical nurse specialist, licensed professional
counselor (LPC), licensed marriage and family therapist
(LMFT), nurse practitioner (NP), physician assistant (PA), or
other Medicare-qualified mental health care professional as
allowed under applicable state laws.
[Also list any additional benefits offered.]

[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Outpatient rehabilitation services
Covered services include: physical therapy, occupational
therapy, and speech language therapy.
Outpatient rehabilitation services are provided in various
outpatient settings, such as hospital outpatient departments,
independent therapist offices, and Comprehensive Outpatient
Rehabilitation Facilities (CORFs).
Outpatient substance abuse services
[Describe the plan’s benefits for outpatient substance abuse
services.]
Outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers
Note: If you are having surgery in a hospital facility, you
should check with your provider about whether you will be an
inpatient or outpatient. Unless the provider writes an order to
admit you as an inpatient to the hospital, you are an outpatient
and pay the cost-sharing amounts for outpatient surgery. Even
if you stay in the hospital overnight, you might still be
considered an outpatient.

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

[List copays / coinsurance /
deductible]
[List copays / coinsurance /
deductible]

Partial hospitalization services
Partial hospitalization is a structured program of active
[List copays / coinsurance /
psychiatric treatment provided as a hospital outpatient service deductible]
or by a community mental health center, that is more intense
than the care received in your doctor’s or therapist’s office and
is an alternative to inpatient hospitalization.
[Plans that do not have an in-network community mental
health center may add: Note: Because there are no
community mental health centers in our network, we cover
partial hospitalization only as a hospital outpatient service.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Physician/Practitioner services, including doctor’s office
visits
Covered services include:
•

•
•
•

•

Medically-necessary medical care or surgery services
furnished in a physician’s office, certified ambulatory
surgical center, hospital outpatient department, or any
other location
Consultation, diagnosis, and treatment by a specialist
Basic hearing and balance exams performed by your
[insert as applicable: PCP OR specialist], if your doctor
orders it to see if you need medical treatment
[Insert if providing any MA additional telehealth benefits
consistent with 42 CFR § 422.135 in the plan’s CMSapproved Plan Benefit Package submission: Certain
telehealth services, including: [insert general description
of covered MA additional telehealth benefits, i.e., the
specific Part B service(s) the plan has identified as
clinically appropriate to furnish through electronic
exchange when the provider is not in the same location as
the enrollee. Plans may wish to refer enrollees to their
medical coverage policy here.]
o You have the option of getting these services through
an in-person visit or by telehealth. If you choose to get
one of these services by telehealth, you must use a
network provider who offers the service by telehealth.
[Modify as necessary if plan benefits include out-ofnetwork coverage of additional telehealth services as
mandatory supplemental benefits.]
o [List the available means of electronic exchange used
for each Part B service offered as an MA additional
telehealth benefit along with any other access
instructions that may apply.]]
[Insert if the plan’s service area and providers/locations
qualify for telehealth services under original Medicare
requirements in section 1834(m) of the Act: Some
telehealth services including consultation, diagnosis, and
treatment by a physician or practitioner, for patients in
certain rural areas or other places approved by Medicare]
Telehealth services for monthly end-stage renal diseaserelated visits for home dialysis members in a hospitalbased or critical access hospital-based renal dialysis
center, renal dialysis facility, or the member’s home

What you must pay when
you get these services
[List copays / coinsurance /
deductible]
[If applicable, indicate
whether there are different
cost-sharing amounts for
Part B service(s) furnished
through an in-person visit
and those furnished through
electronic exchange as MA
additional telehealth
benefits.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
•
•
•

•
•

•

•
•
•

•

Telehealth services to diagnose, evaluate, or treat
symptoms of a stroke, regardless of your location
Telehealth services for members with a substance use
disorder or co-occurring mental health disorder,
regardless of their location
Telehealth services for diagnosis, evaluation, and
treatment of mental health disorders if:
o You have an in-person visit within 6 months prior to
your first telehealth visit
o You have an in-person visit every 12 months while
receiving these telehealth services
o Exceptions can be made to the above for certain
circumstances
Telehealth services for mental health visits provided by
Rural Health Clinics and Federally Qualified Health
Centers
Virtual check-ins (for example, by phone or video chat)
with your doctor for 5-10 minutes if:
o You’re not a new patient and
o The check-in isn’t related to an office visit in the past 7
days and
o The check-in doesn’t lead to an office visit within 24
hours or the soonest available appointment
Evaluation of video and/or images you send to your
doctor, and interpretation and follow-up by your doctor
within 24 hours if:
o You’re not a new patient and
o The evaluation isn’t related to an office visit in the past
7 days and
o The evaluation doesn’t lead to an office visit within 24
hours or the soonest available appointment
Consultation your doctor has with other doctors by
phone, internet, or electronic health record
Second opinion [Insert if appropriate: by another
network provider] prior to surgery
Non-routine dental care (covered services are limited to
surgery of the jaw or related structures, setting fractures
of the jaw or facial bones, extraction of teeth to prepare
the jaw for radiation treatments of neoplastic cancer
disease, or services that would be covered when provided
by a physician)
[Also list any additional benefits offered.]

What you must pay when
you get these services

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Podiatry services
Covered services include:
Diagnosis and the medical or surgical treatment of
injuries and diseases of the feet (such as hammer toe or
heel spurs)
• Routine foot care for members with certain medical
conditions affecting the lower limbs
[Also list any additional benefits offered.]
•

Prostate cancer screening exams
For men aged 50 and older, covered services include the
following - once every 12 months:
• Digital rectal exam
• Prostate Specific Antigen (PSA) test
[Also list any additional benefits offered.]

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
an annual PSA test.

Prosthetic devices and related supplies
Devices (other than dental) that replace all or part of a body
[List copays / coinsurance /
part or function. These include but are not limited to:
deductible]
colostomy bags and supplies directly related to colostomy
care, pacemakers, braces, prosthetic shoes, artificial limbs, and
breast prostheses (including a surgical brassiere after a
mastectomy). Includes certain supplies related to prosthetic
devices, and repair and/or replacement of prosthetic devices.
Also includes some coverage following cataract removal or
cataract surgery – see Vision Care later in this section for
more detail.
Pulmonary rehabilitation services
Comprehensive programs of pulmonary rehabilitation are
covered for members who have moderate to very severe
chronic obstructive pulmonary disease (COPD) and [insert as
appropriate: a referral OR an order] for pulmonary
rehabilitation from the doctor treating the chronic respiratory
disease.
[Also list any additional benefits offered.]

[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Screening and counseling to reduce alcohol misuse
We cover one alcohol misuse screening for adults with
Medicare (including pregnant women) who misuse alcohol but
aren’t alcohol dependent.
If you screen positive for alcohol misuse, you can get up to 4
brief face-to-face counseling sessions per year (if you’re
competent and alert during counseling) provided by a
qualified primary care doctor or practitioner in a primary care
setting.
[Also list any additional benefits offered.]
Screening for lung cancer with low dose computed
tomography (LDCT)
For qualified individuals, a LDCT is covered every 12
months.
Eligible members are: people aged 50 – 77 years who have
no signs or symptoms of lung cancer, but who have a history
of tobacco smoking of at least 20 pack-years and who
currently smoke or have quit smoking within the last 15 years,
who receive a written order for LDCT during a lung cancer
screening counseling and shared decision-making visit that
meets the Medicare criteria for such visits and be furnished by
a physician or qualified non-physician practitioner.
For LDCT lung cancer screenings after the initial LDCT
screening: the members must receive a written order for
LDCT lung cancer screening, which may be furnished during
any appropriate visit with a physician or qualified nonphysician practitioner. If a physician or qualified nonphysician practitioner elects to provide a lung cancer
screening counseling and shared decision-making visit for
subsequent lung cancer screenings with LDCT, the visit must
meet the Medicare criteria for such visits.

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible for
the Medicare-covered
screening and counseling to
reduce alcohol misuse
preventive benefit.

There is no coinsurance,
copayment, or deductible for
the Medicare covered
counseling and shared
decision-making visit or for
the LDCT.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Screening for sexually transmitted infections (STIs)
and counseling to prevent STIs
We cover sexually transmitted infection (STI) screenings for
chlamydia, gonorrhea, syphilis, and Hepatitis B. These
screenings are covered for pregnant women and for certain
people who are at increased risk for an STI when the tests are
ordered by a primary care provider. We cover these tests once
every 12 months or at certain times during pregnancy.
We also cover up to two individual 20 to 30 minute, face-toface high-intensity behavioral counseling sessions each year
for sexually active adults at increased risk for STIs. We will
only cover these counseling sessions as a preventive service if
they are provided by a primary care provider and take place in
a primary care setting, such as a doctor’s office.
[Also list any additional benefits offered.]
Services to treat kidney disease
Covered services include:
Kidney disease education services to teach kidney care
and help members make informed decisions about their
care. For members with stage IV chronic kidney disease
when referred by their doctor, we cover up to six sessions
of kidney disease education services per lifetime
• Outpatient dialysis treatments (including dialysis
treatments when temporarily out of the service area, as
explained in Chapter 3, or when your provider for this
service is temporarily unavailable or inaccessible)
• Inpatient dialysis treatments (if you are admitted as an
inpatient to a hospital for special care)
• Self-dialysis training (includes training for you and
anyone helping you with your home dialysis treatments)
• Home dialysis equipment and supplies
• Certain home support services (such as, when necessary,
visits by trained dialysis workers to check on your home
dialysis, to help in emergencies, and check your dialysis
equipment and water supply)
Certain drugs for dialysis are covered under your Medicare
Part B drug benefit. For information about coverage for Part B
Drugs, please go to the section, Medicare Part B prescription
drugs.
•

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible for
the Medicare-covered
screening for STIs and
counseling for STIs
preventive benefit.

[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Skilled nursing facility (SNF) care
(For a definition of skilled nursing facility care, see Chapter
12 of this document. Skilled nursing facilities are sometimes
called SNFs.)
[List days covered and any restrictions that apply, including
whether any prior hospital stay is required.] Covered services
include but are not limited to:
Semiprivate room (or a private room if medically
necessary)
• Meals, including special diets
• Skilled nursing services
• Physical therapy, occupational therapy, and speech
therapy
• Drugs administered to you as part of your plan of care
(this includes substances that are naturally present in the
body, such as blood clotting factors.)
• Blood - including storage and administration. Coverage
of whole blood and packed red cells begins only with the
fourth pint of blood that you need - you must either pay
the costs for the first three pints of blood you get in a
calendar year or have the blood donated by you or
someone else. All other components of blood are covered
beginning with the first pint used. [Modify as necessary if
the plan begins coverage with an earlier pint.]
• Medical and surgical supplies ordinarily provided by
SNFs
• Laboratory tests ordinarily provided by SNFs
• X-rays and other radiology services ordinarily provided
by SNFs
• Use of appliances such as wheelchairs ordinarily
provided by SNFs
• Physician/Practitioner services
Generally, you will get your SNF care from network facilities.
However, under certain conditions listed below, you may be
able to pay in-network cost sharing for a facility that isn’t a
network provider, if the facility accepts our plan’s amounts for
payment.
•

•

A nursing home or continuing care retirement community
where you were living right before you went to the
hospital (as long as it provides skilled nursing facility
care)
A SNF where your spouse or domestic partner is living at
the time you leave the hospital

[List copays / coinsurance /
deductible. If cost sharing is
based on benefit period,
include definition /
explanation of BID approved
benefit period here.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Smoking and tobacco use cessation (counseling to stop
smoking or tobacco use)
If you use tobacco, but do not have signs or symptoms of
tobacco-related disease: We cover two counseling quit
attempts within a 12-month period as a preventive service
with no cost to you. Each counseling attempt includes up to
four face-to-face visits.
If you use tobacco and have been diagnosed with a tobaccorelated disease or are taking medicine that may be affected by
tobacco: We cover cessation counseling services. We cover
two counseling quit attempts within a 12-month period,
however, you will pay the applicable cost sharing. Each
counseling attempt includes up to four face-to-face visits.
[Also list any additional benefits offered.]
Special Supplemental Benefits for the Chronically Ill
[Enrollees with chronic condition(s) that meet certain criteria
may be eligible for supplemental benefits for the chronically
ill. The chronic conditions and benefits must be listed here.
The benefits listed here must be approved in the bid. Describe
the nature of the benefits and eligibility criteria here.
If this benefit is not applicable, plans should delete this row.]

What you must pay when
you get these services
There is no coinsurance,
copayment, or deductible for
the Medicare-covered
smoking and tobacco use
cessation preventive benefits.

[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Supervised Exercise Therapy (SET)
SET is covered for members who have symptomatic
peripheral artery disease (PAD) [Optional: and a referral for
PAD from the physician responsible for PAD treatment].
Up to 36 sessions over a 12-week period are covered if the
SET program requirements are met.
The SET program must:
Consist of sessions lasting 30-60 minutes, comprising a
therapeutic exercise-training program for PAD in patients
with claudication
• Be conducted in a hospital outpatient setting or a
physician’s office
• Be delivered by qualified auxiliary personnel necessary to
ensure benefits exceed harms, and who are trained in
exercise therapy for PAD
• Be under the direct supervision of a physician, physician
assistant, or nurse practitioner/clinical nurse specialist
who must be trained in both basic and advanced life
support techniques
SET may be covered beyond 36 sessions over 12 weeks for an
additional 36 sessions over an extended period of time if
deemed medically necessary by a health care provider.
[Also list any additional benefits offered.]
•

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Urgently needed services
Urgently needed services are provided to treat a nonemergency, unforeseen medical illness, injury, or condition
that requires immediate medical care but given your
circumstances, it is not possible, or it is unreasonable, to
obtain services from network providers. If it is unreasonable
given your circumstances to immediately obtain the medical
care from a network provider, then your plan will cover the
urgently needed services from a provider out-of-network.
Services must be immediately needed and medically
necessary. Examples of urgently needed services that the plan
must cover out of network occur if: You are temporarily
outside the service area of the plan and require medically
needed immediate services for an unforeseen condition but it
is not a medical emergency; or it is unreasonable given your
circumstances to immediately obtain the medical care from a
network provider. Cost sharing for necessary urgently needed
services furnished out-of-network is the same as for such
services furnished in-network.
[Include in-network benefits. Also identify whether this
coverage is within the U.S. or as a supplemental world-wide
emergency/urgent coverage.]

What you must pay when
you get these services
[List copays / coinsurance.
Plans should include
different copayments for
contracted urgent care
centers, if applicable.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services that are covered for you
Vision care
Covered services include:
Outpatient physician services for the diagnosis and
treatment of diseases and injuries of the eye, including
treatment for age-related macular degeneration. Original
Medicare doesn’t cover routine eye exams (eye
refractions) for eyeglasses/contacts
• For people who are at high risk of glaucoma, we will
cover one glaucoma screening each year. People at high
risk of glaucoma include: people with a family history of
glaucoma, people with diabetes, African Americans who
are age 50 and older and Hispanic Americans who are 65
or older
• For people with diabetes, screening for diabetic
retinopathy is covered once per year
• [Adapt this description if the plan offers more than is
covered by Original Medicare.] One pair of eyeglasses or
contact lenses after each cataract surgery that includes
insertion of an intraocular lens (If you have two separate
cataract operations, you cannot reserve the benefit after
the first surgery and purchase two eyeglasses after the
second surgery.)
[Also list any additional benefits offered such as supplemental
vision exams or glasses. If the additional vision benefits are
optional supplemental benefits, they should not be included in
the benefits chart; they should be described within Section
2.2.]
•

Welcome to Medicare preventive visit
The plan covers the one-time Welcome to Medicare
preventive visit. The visit includes a review of your health, as
well as education and counseling about the preventive services
you need (including certain screenings and shots), and
referrals for other care if needed.
Important: We cover the Welcome to Medicare preventive
visit only within the first 12 months you have Medicare Part
B. When you make your appointment, let your doctor’s office
know you would like to schedule your Welcome to Medicare
preventive visit.

What you must pay when
you get these services
[List copays / coinsurance /
deductible]

There is no coinsurance,
copayment, or deductible for
the Welcome to Medicare
preventive visit.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Section 2.2

Extra optional supplemental benefits you can buy

[Include this section if you offer optional supplemental benefits in the plan and describe benefits
below. You may include this section either in the EOC or as an insert to the EOC.]
Our plan offers some extra benefits that are not covered by Original Medicare and not included
in your benefits package. These extra benefits are called Optional Supplemental Benefits. If
you want these optional supplemental benefits, you must sign up for them [insert if applicable:
and you may have to pay an additional premium for them]. The optional supplemental benefits
described in [insert as applicable: this section OR the enclosed insert] are subject to the same
appeals process as any other benefits.
[Insert plan specific optional benefits, premiums, deductible, copays and coinsurance and rules
using a chart like the Benefits Chart above. Insert plan specific procedures on how to elect
optional supplemental coverage, including application process and effective dates and on how to
discontinue optional supplemental coverage, including refund of premiums. Also insert any
restrictions on members’ re-applying for optional supplemental coverage (e.g., must wait until
next annual enrollment period).]
Section 2.3

Getting care using our plan’s optional visitor/traveler benefit

[If your plan offers a visitor/traveler program to members who are out of your service area,
insert this section, adapting and expanding the following paragraphs as needed to describe the
traveler benefits and rules related to receiving the out-of-area coverage. If you allow extended
periods of enrollment out-of-area per the exception in 42 CFR 422.74(b)(4)(iii) (for more than
six months up to 12 months) also explain that here based on the language suggested below.
If you do not permanently move, but you are continuously away from our plan’s service area for
more than six months, we usually must disenroll you from our plan. However, we offer a
visitor/traveler program [specify areas where the visitor/traveler program is being offered],
which will allow you to remain enrolled when you are outside of our service area for less than 12
months. Under our visitor/traveler program you may receive all plan covered services at innetwork cost sharing. Please contact the plan for assistance in locating a provider when using the
visitor/traveler benefit.
If you are in the visitor/traveler area, you can stay enrolled in our plan for up to 12 months. If
you have not returned to the plan’s service area within 12 months, you will be disenrolled from
the plan.]

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Chapter 4 Medical Benefits Chart (what is covered and what you pay)

SECTION 3

What services are not covered by the plan?

Section 3.1

Services we do not cover (exclusions)

This section tells you what services are excluded from Medicare coverage and therefore, are not
covered by this plan.
The chart below lists services and items that either are not covered under any condition or are
covered only under specific conditions.
If you get services that are excluded (not covered), you must pay for them yourself except under
the specific conditions listed below. Even if you receive the excluded services at an emergency
facility, the excluded services are still not covered, and our plan will not pay for them. The only
exception is if the service is appealed and decided upon appeal to be a medical service that we
should have paid for or covered because of your specific situation. (For information about
appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 5.3
in this document.)
[The services listed in the chart below are excluded from Original Medicare’s benefit package. If
any services below are covered supplemental benefits, delete them from this list. When plans
partially exclude services excluded by Medicare, they do not need to delete the item completely
but may revise the text accordingly to describe the extent of the exclusion. Plans may add
parenthetical references to the Benefits Chart for descriptions of covered services/items as
appropriate. Plans may reorder the below excluded services alphabetically, if they wish. Plans
may also add exclusions as needed.]
Services not covered by
Medicare
Acupuncture
Cosmetic surgery or
procedures

Not covered under
any condition

Covered only under specific
conditions
• Available for people with
chronic low back pain under
certain circumstances.
• Covered in cases of an
accidental injury or for
improvement of the functioning
of a malformed body member.
• Covered for all stages of
reconstruction for a breast after a
mastectomy, as well as for the
unaffected breast to produce a
symmetrical appearance.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services not covered by
Medicare
Custodial care

Not covered under
any condition

Homemaker services include
basic household assistance,
including light housekeeping
or light meal preparation.
Naturopath services (uses
natural or alternative
treatments).
Non-routine dental care
Orthopedic shoes or supportive
devices for the feet

Covered only under specific
conditions

√

Custodial care is personal care
that does not require the
continuing attention of trained
medical or paramedical
personnel, such as care that
helps you with activities of
daily living, such as bathing or
dressing.
Experimental medical and
surgical procedures,
equipment, and medications.
Experimental procedures and
items are those items and
procedures determined by
Original Medicare to not be
generally accepted by the
medical community.
Fees charged for care by your
immediate relatives or
members of your household.
Full-time nursing care in your
home.
Home-delivered meals

May be covered by Original
Medicare under a Medicareapproved clinical research study or
by our plan.
(See Chapter 3, Section 5 for more
information on clinical research
studies.)

√
√
√
√
√
Dental care required to treat illness
or injury may be covered as
inpatient or outpatient care.
Shoes that are part of a leg brace and
are included in the cost of the brace.
Orthopedic or therapeutic shoes for
people with, diabetic foot disease.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 Medical Benefits Chart (what is covered and what you pay)

Services not covered by
Medicare
Personal items in your room at
a hospital or a skilled nursing
facility, such as a telephone or
a television.
Private room in a hospital.

Not covered under
any condition

Covered only under specific
conditions

√
Covered only when medically
necessary.

Reversal of sterilization
procedures and or nonprescription contraceptive
supplies.
Routine chiropractic care

√

Routine dental care, such as
cleanings, fillings, or dentures.
Routine eye examinations,
eyeglasses, radial keratotomy,
LASIK surgery, and other low
vision aids.
Routine foot care

√

Routine hearing exams,
hearing aids, or exams to fit
hearing aids.
Services considered not
reasonable and necessary,
according to Original Medicare
standards

√

Manual manipulation of the spine to
correct a subluxation is covered.

Eye exam and one pair of eyeglasses
(or contact lenses) are covered for
people after cataract surgery.
Some limited coverage provided
according to Medicare guidelines
(e.g., if you have diabetes).

√

CHAPTER 5:

Using the plan’s coverage
for Part D prescription drugs

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 5 Using the plan’s coverage for Part D prescription drugs

SECTION 1

101

Introduction

This chapter explains rules for using your coverage for Part D drugs. Please see Chapter 4 for
Medicare Part B drug benefits and hospice drug benefits.
Section 1.1

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 you a prescription
which must be valid under applicable state law.

•

Your prescriber must not be on Medicare’s Exclusion or Preclusion Lists.

•

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

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 on
the plan’s “Drug List.”
Section 2.2

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]), and/or call Member Services.

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You may go to any of our network pharmacies. [Insert if plan has pharmacies that offer
preferred cost sharing in its network: Some of our network pharmacies provide preferred cost
sharing, which may be lower than the cost sharing at a pharmacy that offers standard cost
sharing. The Pharmacy Directory will tell you which of the network pharmacies offer preferred
cost sharing. Contact us to find out more about how your out-of-pocket costs could vary for
different drugs.]
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 network or preferred pharmacy, if available.] To find another pharmacy in your
area, you can get help from Member Services 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?
Some 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 LTC facility (such as a nursing home) has its own pharmacy. 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.
Section 2.3

Using the plan’s mail-order service

[Omit 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 service. Generally, the drugs provided through mail order are drugs

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that you take on a regular basis, for a chronic or long-term medical condition. [Insert if plan
marks mail-order drugs in formulary: These drugs 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 be delivered 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 will automatically process new prescriptions consistent with the policy
described in the December 12, 2013, HPMS memo and 2016 Final Call Letter; and ii) whether
the sponsor offers an optional automatic refill program consistent with policy described in the
2020 Final Call Letter. Sponsors who provide automatic delivery through retail or other nonmail 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: Sponsors that do not automatically process new prescriptions from provider offices,
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. It is important that
you respond each time you are contacted by the pharmacy, to let them know whether to
ship, delay, or stop the new prescription.]
[Option 2: Sponsors that do automatically process new prescriptions from provider offices,
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

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•

104

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 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. It is important that you respond each time you are contacted by the
pharmacy, to let them know whether to ship, delay, or cancel the new prescription.
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 your current prescription 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 need 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 but still want the mail-order pharmacy to
send you your prescription, please contact your pharmacy [insert recommended number
of days] days before your current prescription will run out. This will ensure your 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].]

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If you receive a refill automatically by mail that you do not want, you may be eligible for
a refund.
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.)
1. [Delete if plan does not offer extended-day supplies through retail pharmacies.] [Insert if
applicable: Some retail pharmacies in our network allow you to get a long-term supply of
maintenance drugs [insert if applicable: (which offer preferred cost sharing)] [insert if
applicable: at [insert as appropriate: a lower OR the mail-order] cost-sharing amount.]
[Insert if applicable: Other retail pharmacies may not agree to the [insert as appropriate:
lower OR mail-order] cost-sharing amounts. 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.
2. [Delete if plan does not offer mail-order service.] You may also receive maintenance
drugs through our mail-order program. Please see Section 2.3 for more information.
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.] Please
check first with Member Services to see if there is a network pharmacy nearby. You will most
likely 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.
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).]

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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 cost share) at the time you fill your prescription. You can ask us to reimburse
you for our share of the cost. (Chapter 7, 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 meets Medicare’s requirements and has been approved by Medicare.
The drugs on the “Drug List” are only those covered under Medicare Part D.
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 for the diagnosis or condition for which
it is being prescribed.

•

-- or -- Supported by certain references, such as the American Hospital Formulary
Service Drug Information and the DRUGDEX Information System.

[Plans that are not offering indication-based formulary design should delete this section] Certain
drugs may be covered for some medical conditions but are considered non-formulary for other
medical conditions. These drugs will be identified on our “Drug List” and in Medicare Plan
Finder, along with the specific medical conditions that they cover.
[Insert either of the two sentences: The “Drug List” includes brand name drugs and generic
drugs. OR The “Drug List” includes brand name drugs, generic drugs, and biosimilars.]
A brand name drug is a prescription drug that is sold under a trademarked name owned by the
drug manufacturer. Brand name drugs that are more complex than typical drugs (for example,
drugs that are based on a protein) are called biological products. On the “Drug List,” when we
refer to drugs, this could mean a drug or a biological product.
A generic drug is a prescription drug that has the same active ingredients as the brand name drug.
[Insert if applicable: Since biological products are more complex than typical drugs, instead of
having a generic form, they have alternatives that are called biosimilars.] Generally, generics
[Insert if applicable: and biosimilars] work just as well as the brand name drug [Insert if

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Chapter 5 Using the plan’s coverage for Part D prescription drugs

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applicable: or biological product] and usually cost less. There are generic drug substitutes [Insert
if applicable: or biosimilar alternatives] available for many brand name drugs [Insert if
applicable: and some biological products].
[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.] [Plans that offer both a Part C and Part D over the counter benefit should explain i)
what can be purchased by each program, ii) what can be purchased by both programs, iii) the
effects of using one program or the other.]
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 information about this, see Section 7.1 in this chapter).

•

In other cases, we have decided not to include a particular drug on the “Drug
List.” In some cases, you may be able to obtain a drug that is not on the “Drug
List.” For more information, please see Chapter 9.

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 6 (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:

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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.
4. Use the plan’s “Real Time Benefit Tool” ([insert URL] or by calling Member
Services). With this tool you can search for drugs on the “Drug List” to see an
estimate of what you will pay and if there are alternative drugs on the “Drug List”
that could treat the same condition. [Plans may insert additional information
about the Real Time Benefit Tool such as rewards and incentives which may be
offered to enrollees who use the “Real Time Benefit Tool.”]
5. [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 encourage you and your provider to use
drugs in the most effective ways. To find out if any of these restrictions apply to a drug you take
or want to take, check the “Drug List.” If 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.
Please note that sometimes a drug may appear more than once on our “Drug List.” This is
because the same drugs can differ based on the strength, amount, or form of the drug prescribed
by your health care provider, and different restrictions or cost sharing may apply to the different
versions of the drug (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet
versus liquid).
Section 4.2

What kinds of restrictions?

The sections below tell you more about the types of restrictions we use for certain drugs.
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. 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

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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 9)
[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 instead of the
brand name drug. 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. This is put in place to ensure
medication safety and help 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 usually 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 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.

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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

There are situations where there is a prescription drug you are 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.

•

[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.

•

There are things you can do if your drug is not covered in the way that you’d like it to be
covered. 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 options:
•

You may be able to get a temporary supply of the drug.

•

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 must provide a temporary supply of a drug that you are
already taking. This temporary supply gives you time to talk with your provider about the change
in coverage and decide what to do.
To be eligible for a temporary supply, the drug you have been taking must no longer be on the
plan’s “Drug List” OR is now restricted in some way.

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•

If you are a new member, 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 in the plan last year, we will cover a temporary supply of your drug during
the first [insert time period (must be at least 90 days)] of the calendar year.

•

This temporary supply will be for a maximum of [insert supply limit (must be at least the
number of days in the plan’s one-month 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 the number of days in the plan’s one-month supply)] of medication. The
prescription must be filled at a network pharmacy. (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 facility and need a supply
right away:
We will cover one [insert supply limit (must be at least a 31-day supply)] emergency
supply of a particular drug, or less if your prescription is written for fewer days. This is in
addition to the above temporary supply.
[If applicable: Plans must insert their transition policy for current members with level of
care changes.]

For questions about a temporary supply, call Member Services.
During the time when you are using a temporary supply of a drug, you should talk with your
provider to decide what to do when your temporary supply runs out. You have two options:
1) You can change to another drug
Talk with your provider about whether there is a different drug covered by the plan that may
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.
2) You can ask for an exception
You and your provider can ask the plan to make an exception and cover the drug in the way you
would like it 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. 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 tell you about any change prior to
the new 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.

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If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells you 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, talk to your provider. There may be a
different drug in a lower cost-sharing tier that might work just as well for you. 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.
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 9, Section 6.4 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 the plan designated one of its tiers as a specialty tier for unique/high-cost drugs and is
exempting that tier from the exceptions process: Drugs in our [insert tier number and name of
the tier designated as the specialty tier] are not eligible for this type of exception. We do not
lower the cost-sharing amount for drugs in this tier.]
[Insert if the plan designated two of its tiers as specialty tiers, such that one of the specialty tiers
is a preferred specialty tier with lower cost sharing relative to the other specialty tier and is
exempting both of those tiers from the exceptions process to lower (non-specialty) tiers: Drugs in
our [insert tier number and name of tier designated as the higher cost-sharing specialty tier] are
eligible for this type of exception to our [insert tier number and name of the tier designated as
the preferred specialty tier]. However, drugs in our [insert tier numbers and names of two tiers
designated as specialty tiers] are not eligible for this type of exception to [insert tier numbers
and names of the non-specialty tiers below the tiers designated as specialty tiers].

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SECTION 6

What if your coverage changes for one of your
drugs?

Section 6.1

The “Drug List” can change during the year

113

Most of the changes in drug coverage happen at the beginning of each year (January 1).
However, during the year, the plan can make some changes to the “Drug List.” For example, the
plan might:
•

Add or remove drugs from the “Drug List.”

•

[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.

•

Replace a brand name drug with a generic drug.

We must follow Medicare requirements before we change the plan’s “Drug List.”
Section 6.2

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

Information on changes to drug coverage
When changes to the “Drug List” occur, we post information on our website about those
changes. We also update our online “Drug List” on a regularly scheduled basis. Below we point
out the times that you would get direct notice if changes are made to a drug that you are taking.
Changes to your drug coverage that affect you during the current plan year
[Plan sponsors that otherwise meet all requirements and want the option to immediately replace
brand name drugs with their new generic equivalents should insert A directly below and insert a
clause on generics not new to market in the section on other changes to the “Drug List.” Plan
sponsors that will not be using the option to make immediate substitutions of new generic drugs
should insert B.]
[A. Advance General Notice that plan sponsor may immediately substitute new generic drugs:
In order to immediately replace brand name drugs with new therapeutically equivalent generic
drugs (or change the tiering or the restrictions, or both, applied to a brand name drug after
adding a new generic drug), plan sponsors that otherwise meet the requirements must provide
the following advance general notice of changes:
•

A new generic drug replaces a brand name drug on the “Drug List” (or we change
the cost-sharing tier or add new restrictions to the brand name drug or both)

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o We may immediately remove a brand name drug on our “Drug List” if we are
replacing it with a newly approved generic version of the same drug. The generic
drug will appear on the same or lower cost-sharing tier and with the same or
fewer restrictions. We may decide to keep the brand name drug on our “Drug
List,” but immediately move it to a higher cost-sharing tier or add new restrictions
or both when the new generic is added.
o We may not tell you in advance before we make that change—even if you are
currently taking the brand name drug. If you are taking the brand name drug at the
time we make the change, we will provide you with information about the specific
change(s). This will also include information on the steps you may take to request
an exception to cover the brand name drug. You may not get this notice before we
make the change.
o You or your prescriber can ask us 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 9.]
[B. Information on generic substitutions for plan sponsors that will not be immediately
substituting new generic drugs. Plan sponsors that will not be making any immediate
substitutions of new generic drugs should insert the following:
•

A generic drug replaces a brand name drug on the “Drug List” (or we change the
cost-sharing tier or add new restrictions to the brand name drug or both)
o We may remove a brand name drug from our “Drug List” if we are replacing it
with a generic version of the same drug. We may decide to keep the brand name
drug on our “Drug List,” but move it to a higher cost-sharing tier or add new
restrictions or both when the generic is added.
o If a brand name drug you are taking is replaced by a generic or moved to a higher
cost-sharing tier, we must give you at least 30 days’ advance notice of the change
or give you notice of the change and a [insert supply limit (must be at least the
number of days in the plan’s one-month supply)] -day refill of your brand name
drug.
o After you receive notice of the change, you should work with your provider to
switch to the generic or to a different drug that we cover.
o You or your prescriber can ask us 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 9.]

[All plan sponsors should include the remainder of this section, with applicable clause noted
below.]
•

Unsafe drugs and other drugs on the “Drug List” that are withdrawn from the
market

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o Sometimes a drug may be deemed unsafe or taken off the market for another
reason. If this happens, we may immediately remove the drug from the “Drug
List.” If you are taking that drug, we will tell you right away.
o Your prescriber will also know about this change and can work with you to find
another drug for your condition.
•

Other changes to drugs on the “Drug List”
o We may make other changes once the year has started that affect drugs you are
taking. For example, [plan sponsors that want the option to immediately substitute
new generic drugs insert: we might add a generic drug that is not new to the
market to replace a brand name drug on the “Drug List” or change the costsharing tier or add new restrictions to the brand name drug or both. We also] OR
[plan sponsors that will not be making immediate generic substitutions insert: we]
might make changes based on FDA boxed warnings or new clinical guidelines
recognized by Medicare.
o For these changes, we must give you at least 30 days’ advance notice of the
change or give you notice of the change and a [insert supply limit (must be at
least the number of days in the plan’s one-month supply)] -day refill of the drug
you are taking at a network pharmacy.
o After you receive notice of the change, you should work with your prescriber to
switch to a different drug that we cover or to satisfy any new restrictions on the
drug you are taking.
o You or your prescriber can ask us to make an exception and continue to cover the
drug for you. For information on how to ask for an exception, see Chapter 9.

Changes to the “Drug List” that do not affect you during this plan year
We may make certain changes to the “Drug List” that are not described above. In these cases, the
change will not apply to you if you are taking the drug when the change is made; however, these
changes will likely affect you starting January 1 of the next plan year if you stay in the same
plan.
In general, changes that will not affect you during the current plan year are:
•

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

•

We put a new restriction on the use of your drug.

•

We remove your drug from the “Drug List.”

If any of these changes happen for a drug you are taking (except for market withdrawal, a
generic drug replacing a brand name drug, or other change noted in the sections above), 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
restrictions to your use of the drug.

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We will not tell you about these types of changes directly during the current plan year. You will
need to check the “Drug List” for the next plan year (when the list is available during the open
enrollment period) to see if there are any changes to the drugs you are taking that will impact you
during the next plan year.

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 [insert if applicable: (except
for certain excluded drugs covered under our enhanced drug coverage)]. If you appeal and the
requested drug is found not to be excluded under Part D, we will pay for or cover it. (For
information about appealing a decision, go to Chapter 9.)
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 or 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.

•

Coverage for off-label use is allowed only when the use is supported by certain
references, such as the American Hospital Formulary Service Drug Information and the
DRUGDEX Information System.

In addition, by law, the following 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 used to promote fertility

•

Drugs used for the relief of cough or cold symptoms

•

Drugs used for cosmetic purposes or to promote hair growth

•

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

•

Drugs used for the treatment of sexual or erectile dysfunction

•

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

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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 (enhanced drug
coverage) not normally covered in a Medicare prescription drug plan. [Insert details about the
excluded drugs your plan does cover, including whether you place any limits on that coverage.]
The amount you pay for these drugs does not count towards qualifying you for the Catastrophic
Coverage Stage. (The Catastrophic Coverage Stage is described in Chapter 6, Section 7 of this
document.)]
In addition, if you are receiving “Extra Help” to pay for your prescriptions, the “Extra Help”
program will not pay for the drugs not normally covered. 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.)]

SECTION 8

Filling a prescription

Section 8.1

Provide your membership information

To fill your prescription, provide your plan membership information, which can be found on
your membership card, at the network pharmacy you choose. The network pharmacy will
automatically bill the plan for our share of your 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 information with
you?

If you don’t have your plan membership information with you when you fill your prescription,
you or the pharmacy can 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 7, Section 2.1 for information about how to ask the plan for reimbursement.)

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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 the plan?

118

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we
will generally cover the cost of your prescription drugs during your stay. Once you leave the
hospital or skilled nursing facility, the plan will cover your prescription drugs as long as the
drugs meet all of our rules for coverage described in this Chapter.
Section 9.2

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

Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy or uses a
pharmacy that supplies drugs for all of its residents. If you are a resident of a LTC facility, you
may get your prescription drugs through the facility’s pharmacy or the one it uses, as long as it is
part of our network.
Check your Pharmacy Directory to find out if your LTC facility’s pharmacy or the one that it
uses is part of our network. If it isn’t, or if you need more information or assistance, please
contact Member Services. 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.
What if you’re a resident in a long-term care (LTC) facility and need a drug that is
not on our “Drug List” or is restricted in some way?
Please refer to Section 5.2 about a temporary or emergency supply.
Section 9.3

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

If you currently have other prescription drug coverage through your (or your spouse or domestic
partner’s) employer or retiree group, 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 have employee or retiree group coverage, the drug coverage you get from us
will be secondary to your 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.
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.

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Keep this notice about creditable coverage because you may need it 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 the creditable coverage notice, request a
copy from your employer or retiree plan’s benefits administrator or the employer or union.
Section 9.4

What if you’re in Medicare-certified hospice?

Hospice and our plan do not cover the same drug at the same time. If you are enrolled in
Medicare hospice and require certain drugs (e.g., anti-nausea, laxative, pain medication or
antianxiety drugs) that are 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 these drugs that should be covered by our plan, ask your hospice provider or
prescriber to provide notification before your prescription is filled.
In the event you either revoke your hospice election or are discharged from hospice, our plan
should cover your drugs as explained in this document. To prevent any delays at a pharmacy
when your Medicare hospice benefit ends, bring documentation to the pharmacy to verify your
revocation or discharge.

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.
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
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 for drugs that have ingredients you are allergic to

•

Possible errors in the amount (dosage) of a drug you are taking

•

Unsafe amounts of opioid pain medications

If we see a possible problem in your use of medications, we will work with your provider to
correct the problem.

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120

Drug Management Program (DMP) to help members safely use
their opioid medications

We have a program that helps make sure members safely use prescription opioids and other
frequently abused medications. This program is called a Drug Management Program (DMP). If
you use opioid medications that you get from several doctors or pharmacies, or if you had a
recent opioid overdose, we may talk to your doctors to make sure your use of opioid medications
is appropriate and medically necessary. Working with your doctors, if we decide your use of
prescription opioid [insert if applicable: or benzodiazepine] medications may not be safe, we
may limit how you can get those medications. If we place you in our DMP, the limitations may
be:
•
•
•

Requiring you to get all your prescriptions for opioid [insert if applicable: or
benzodiazepine] medications from a certain pharmacy(ies)
Requiring you to get all your prescriptions for opioid [insert if applicable: or
benzodiazepine] medications from a certain doctor(s)
Limiting the amount of opioid [insert if applicable: or benzodiazepine] medications we
will cover for you

If we plan on limiting how you may get these medications or how much you can get, we will
send you a letter in advance. The letter will tell you if we will limit coverage of these drugs for
you, or if you’ll be required to get the prescriptions for these drugs only from a specific doctor or
pharmacy. You will have an opportunity to tell us which doctors or pharmacies you prefer to use,
and about any other information you think is important for us to know. After you’ve had the
opportunity to respond, if we decide to limit your coverage for these medications, we will send
you another letter confirming the limitation. If you think we made a mistake or you disagree with
our decision or with the limitation, you and your prescriber have the right to appeal. If you
appeal, we will review your case and give you a new decision. If we continue to deny any part of
your request related to the limitations that apply to your access to medications, we will
automatically send your case to an independent reviewer outside of our plan. See Chapter 9 for
information about how to ask for an appeal.
You will not be placed in our DMP if you have certain medical conditions, such as active cancerrelated pain or sickle cell disease, you are receiving hospice, palliative, or end-of-life care, or
live in a long-term care facility.
Section 10.3

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

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. Our [if applicable replace:
Our with One] program is called a Medication Therapy Management (MTM) program. This
program is [if applicable replace with: These programs are] voluntary and free. A team of

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pharmacists and doctors developed the program [insert if applicable: s] for us to help make sure
that our members get the most benefit from the drugs they take.
Some members who take medications for different medical conditions and have high drug costs
or are in a DMP to help members use their opioids safely, may be able to get services through an
MTM program. If you qualify for the program, a pharmacist or other health professional will
give you a comprehensive review of all your medications. During the review, you can talk about
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 which has a recommended todo list that includes steps you should take to get the best results from your medications. You’ll
also get a medication list that will include all the medications you’re taking, how much you take,
and when and why you take them. In addition, members in the MTM program will receive
information on the safe disposal of prescription medications that are controlled substances.
It’s a good idea to talk to your doctor about your recommended to-do list and medication list.
Bring the summary with you to your visit or anytime you talk with your doctors, pharmacists,
and other health care providers. Also, keep your medication list up to date and 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. If you have any questions about this program [if applicable replace with: these programs],
please contact Member Services.

CHAPTER 6:

What you pay for your
Part D prescription drugs

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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.

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 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 5, 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, you need to know what drugs are covered, where to fill
your prescriptions, and what rules to follow when you get your covered drugs. Chapter 5,
Sections 1 through 4 explain these rules. When you use the plan’s “Real Time Benefit Tool” to
look up drug coverage (see Chapter 3, Section 3.3), the cost shown is provided in “real time”
meaning the cost you see in the tool reflects a moment in time to provide an estimate of the outof-pocket costs you are expected to pay. You can also obtain information provided by the “Real
Time Benefit Tool” by calling Member Services.
Section 1.2

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

There are different types of out-of-pocket costs for Part D drugs. The amount that you pay for a
drug is called cost sharing and there are three ways you may be asked to pay.
•

Deductible is the amount you pay for drugs before our plan begins to pay its share.

•

Copayment is a fixed amount you pay each time you fill a prescription.

•

Coinsurance is a percentage of the total cost you pay each time you fill a prescription.

Section 1.3

How Medicare calculates your out-of-pocket costs

Medicare has rules about what counts and what does not count toward your out-of-pocket costs.
Here are the rules we must follow to keep track of your out-of-pocket costs.

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These payments are included in your out-of-pocket costs
Your out-of-pocket costs 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 5):
• The amount you pay for drugs when you are in any of the following drug payment stages:
o [Plans without a deductible, omit] The Deductible Stage
o The Initial Coverage Stage

o [Plans without a Coverage Gap, omit] 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 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 2024 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
Your out-of-pocket costs do not include any of these types of payments:
• [Plans with no premium, omit] 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.

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• [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 the 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 by calling Member Services.

How can you keep track of your out-of-pocket total?
• We will help you. The Part D EOB report you receive includes the current amount of
your out-of-pocket costs. When this amount reaches $[insert 2024 out-of-pocket
threshold], 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.]

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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 2024 plan name]
members?

[Plans participating in the VBID Model and approved to offer VBID reduced or eliminated
Part D cost sharing should update the sections below to reflect the approved Model Benefit(s),
as appropriate.]
There are four drug payment stages for your prescription drug coverage under [insert 2024 plan
name]. How much you pay depends on what stage you are in when you get a prescription filled
or refilled. Details of each stage are in Sections 4 through 7 of this chapter. The stages are:
Stage 1: Yearly Deductible Stage
Stage 2: Initial Coverage Stage
Stage 3: Coverage Gap Stage
Stage 4: Catastrophic Coverage Stage

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 summary 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.

If you have had one or more prescriptions filled through the plan during the previous month, we
will send you a Part D Explanation of Benefits (Part D EOB). The Part D EOB 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 drug costs,
what the plan paid, and what you and others on your behalf paid.

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•

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

•

Drug price information. This information will display the total drug price, and
information about increases in price from first fill for each prescription claim of the same
quantity.

•

Available lower cost alternative prescriptions. This will include information about
other available drugs with lower cost sharing for each prescription claim.

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 every time you get a prescription filled. This helps us
make sure we know about the prescriptions you are filling and what you are paying.

•

Make sure we have the information we need. There are times you may pay for the
entire cost of a prescription drug. In these cases, 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, give us copies of your receipts. Here are examples of when you
should give us copies of your drug receipts:
o 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.
o When you made a copayment for drugs that are provided under a drug
manufacturer patient assistance program.
o 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.
o 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 7, Section 2.

•

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.
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. 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 the Part D EOB look it over
to be sure the information is complete and correct. If you think something is missing or
you have any questions, please call us at Member Services. [Plans that allow members to
manage this information on-line may describe that option here.] Be sure to keep these
reports.

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Chapter 6 What you pay for your Part D prescription drugs

SECTION 4

128

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

[Plans with no deductible replace Section 4 title with: There is no deductible for [insert 2024
plan name]].
[Plans with no deductible replace text below with: There is no deductible for [insert 2024 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 for 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 2024.] [Plans with a
deductible amount other than $0, add: The deductible does not apply to covered insulin products
and most adult Part D vaccines.] [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.] The
full cost is usually lower than the normal full price of the drug since our plan has negotiated
lower costs for most drugs at network pharmacies.
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 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:

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•

[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.]

•

[Plans with copayment/coinsurance on tiers during the Initial Coverage Stage, insert the
following if the insulin cost sharing differs from the cost sharing for other drugs on the
same tier: You pay $[xx] per month supply of each covered insulin product on this tier.]
[Repeat for all drug tiers.]

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 network retail pharmacy.

•

[Plans with retail network pharmacies that offer preferred cost sharing, insert: A
network retail pharmacy that offers standard cost sharing. Costs may be less at
pharmacies that offer preferred 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. We cover prescriptions filled at out-ofnetwork pharmacies in only limited situations. Please see Chapter 5, Section 2.5 to find
out when we will cover a prescription filled at an out-of-network pharmacy.

•

[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 5
and the plan’s Pharmacy Directory.
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.
[Plans that do not use drug tiers, omit] As shown in the table below, the amount of the
copayment or coinsurance depends on the cost-sharing tier.
[Plans without copayments, omit] Sometimes the cost of the drug is lower than your copayment.
In these cases, you pay the lower price for the drug instead of the copayment.
[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 modify the chart to indicate the

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Chapter 6 What you pay for your Part D prescription drugs

different rates. Removed columns do not apply (e.g., preferred cost-sharing or mail-order cost
sharing). 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:
Standard
retail cost
sharing
(in-network)

Preferred
retail cost
sharing (innetwork)

Mail-order
cost sharing

Tier

(up to a
[insert
number of
days]-day
supply)

Cost-Sharing
Tier 1

[Insert copay/
coinsurance]

(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 5 for
details.)
(up to a [insert
number of days]day supply)

([insert
description, e.g.,
generic drugs])
Cost-Sharing
Tier 2
([insert
description])
Cost-Sharing
Tier 3
([insert
description])
Cost-Sharing
Tier 4
([insert
description])

[Plans that offer cost-sharing for insulin that differs from the cost sharing for other drugs on the
same tier, insert the following footnote: You won’t pay more than $35 [update the cost-sharing
amount, if lower than $35] for a one-month supply of each covered insulin product regardless of
the cost-sharing tier [modify as needed if plan offers multiple cost-sharing amounts for insulins
(e.g., preferred and non-preferred insulins)] [insert only if plan’s benefit design includes a
deductible:, even if you haven’t paid your deductible.]
Please see Section 9 of this chapter for more information on Part D vaccines cost sharing for Part
D vaccines.

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Section 5.3

131

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. There may
be times when you or your doctor would like you to have less than a month’s supply of a drug
(for example, when you are trying a medication for the first time). You can also ask your doctor
to prescribe, and your pharmacist to dispense, less than a full month’s supply of your drugs, if
this will help you better plan refill dates for different prescriptions.
If you receive less than a full month’s supply of certain drugs, you will not have to pay for the
full month’s supply.
•

If you are responsible for coinsurance, you pay a percentage of the total cost of the drug.
Since the coinsurance is based on the total cost of the drug, your cost will be lower since
the total cost for the drug will be lower.

•

If you are responsible for a copayment for the drug, you will only pay for the number of
days of the drug that you receive instead of a whole month. 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.

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

[Plans without copayments, omit] Sometimes the cost of the drug is lower than your
copayment. In these cases, you pay the lower price for the drug instead of the copayment.

[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 modify the chart to indicate the
different rates. Remove columns that do not apply (e.g., preferred cost sharing or mail-order cost
sharing) 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].]

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Chapter 6 What you pay for your Part D prescription drugs

Your share of the cost when you get a long-term supply of a covered Part D
prescription drug:
Standard retail cost
sharing
(in-network)

Preferred retail cost
sharing
(in-network)

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]

Cost-Sharing Tier 2
([insert description])

[Insert copay/
coinsurance]

Cost-Sharing Tier 3
([insert description])

[Insert copay/
coinsurance]

Cost-Sharing Tier 4
([insert description])

[Insert copay/
coinsurance]

Tier

[For plans that offer insulin cost sharing different from the cost sharing applicable to the other
drugs on the same tier, insert the following: You won’t pay more than [inset the applicable
language: $70 [update the cost-sharing amount, if lower than $70] for up to a two-month supply
or $105 [update the cost-sharing amount, if lower than $105] for up to a three-month supply] of
each covered insulin product regardless of the cost-sharing tier [modify as needed if plan offers
multiple cost-sharing amounts for insulins (e.g., preferred and non-preferred insulins)] [insert
only if plan’s benefits design includes a deductible: , even if you haven’t paid your deductible.]

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Section 5.5

133

You stay in the Initial Coverage Stage until your [insert as
applicable: total drug costs for the year reach $[insert initial
coverage limit] OR out-of-pocket costs for the year reach
$[insert 2024 out-of-pocket threshold]]

You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have
filled reaches the $[insert initial coverage limit] limit for the Initial Coverage Stage.
[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 2024 out-of-pocket threshold].
You then 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 towards your [insert if plan has a coverage gap: initial coverage limit or] total out-ofpocket costs.]
The Part D EOB that you receive will help you keep track of how much you, the plan, and 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 2024 out-of-pocket threshold]] limit in a
year.
We will let you know if you reach this 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]. See Section 1.3 on how Medicare calculates your out-of-pocket
costs.

SECTION 6

Costs in the Coverage Gap Stage

[Plans with no coverage gap replace Section 6 title with: There is no coverage gap for [insert
2024 plan name].]
[Plans with no coverage gap replace text below with: There is no coverage gap for [insert 2024
plan name]. Once you leave the Initial Coverage Stage, you move on to the Catastrophic
Coverage Stage (see Section 7).]
[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 25% 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.

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You also receive some coverage for generic drugs. You pay no more than 25% of the cost for
generic drugs and the plan pays the rest. Only the amount you pay counts and moves you through
the coverage gap.
You continue paying these costs until your yearly out-of-pocket payments reach a maximum
amount that Medicare has set. Once you reach this amount $[insert 2024 out-of-pocket
threshold], you leave the Coverage Gap Stage and move to the Catastrophic Coverage Stage.
Medicare has rules about what counts and what does not count toward your out-of-pocket costs
(Section 1.3).

SECTION 7

During the Catastrophic Coverage Stage, the plan
pays the full cost for your covered Part D drugs

You enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the
$[insert 2024 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.
•

•

[Plans that do not cover excluded drugs under an enhanced benefit, OR plans that cover
excluded drugs under an enhanced benefit but with the same cost sharing as covered
Part D drugs in this stage (i.e., no cost sharing), insert the following: During this
payment stage, the plan pays the full cost for your covered Part D drugs. You pay
nothing.]
[Plans that cover excluded drugs under an enhanced benefit with cost sharing in this
stage, insert the following two bullets:
o During this payment stage, the plan pays the full cost for your covered Part D
drugs. You pay nothing.
o For excluded drugs covered under our enhanced benefit, you pay [insert copay
of coinsurance amount].]

SECTION 8

Additional benefits information

[Optional: Insert any additional benefits information based on the plan’s approved bid that is
not captured in the sections above.]

SECTION 9

Part D Vaccines. What you pay for depends on how
and where you get them

Important Message About What You Pay for Vaccines – Some vaccines are considered medical
benefits. Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s
List of Covered Drugs (Formulary). Our plan covers most adult Part D vaccines at no cost to you
[insert only if plan’s benefit design includes a deductible: even if you haven’t paid your deductible].
Refer to your plan’s List of Covered Drugs (Formulary) or contact Member Services for coverage
and cost-sharing details about specific vaccines.

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There are two parts to our coverage of Part D vaccinations:
•

The first part of coverage is the cost of the vaccine itself.

•

The second part of coverage is for the cost of giving you the vaccine. (This is sometimes
called the administration of the vaccine.)

Your costs for a Part D vaccination depend on three things:
1. Whether the vaccine is recommended for adults by an organization called the
Advisory Committee or Immunization Practices (ACIP).
•

Most adult Part D vaccinations are recommended by ACIP and cost you nothing.

2. Where you get the vaccine.
•

The vaccine itself may be dispensed by a pharmacy or provided by the doctor’s
office.

3. Who gives you the vaccine.
•

A pharmacist may give the vaccine in the pharmacy, or another provider may give it
in the doctor’s office.

What you pay at the time you get the Part D vaccination can vary depending on the
circumstances and what Drug Stage you are in.
•

Sometimes when you get a vaccination, you have to pay for the entire cost for both the
vaccine itself and the cost for the provider to give you the vaccine. You can ask our plan
to pay you back for our share of the cost. For most adult Part D vaccines, this means you
will be reimbursed the entire cost you paid.

•

Other times, when you get a vaccination, you will pay only your share of the cost under
your Part D benefit. For most adult Part D vaccines, you will pay nothing.

Below are three examples of ways you might get a Part D vaccine.
Situation 1:

Situation 2:

You get the Part D vaccination at the network pharmacy. (Whether you have
this choice depends on where you live. Some states do not allow pharmacies
to give vaccines.)
•

For most adult Part D vaccines, you will pay nothing.

•

For other Part D vaccines, you will pay the pharmacy your [insert as
appropriate: coinsurance OR copayment] for the vaccine itself which
includes the cost of giving you the vaccine.

•

Our plan will pay the remainder of the costs.

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

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•

When you get the vaccine, you will pay for the entire cost of the
vaccine itself and the cost for the provider to give it to you.

•

You can then ask our plan to pay our share of the cost by using the
procedures that are described in Chapter 7.

•

For most adult Part D vaccines, you will be reimbursed the full amount
you paid. For other Part D vaccines, you will be reimbursed the
amount you paid less any [insert as appropriate: coinsurance OR
copayment] for the vaccine (including administration) [Only insert the
following if an out-of-network differential is charged for a vaccine not
identified as an adult ACIP-recommended $0 cost sharing vaccine:
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.)]

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

For most adult Part D vaccines, you will pay nothing for the vaccine
itself.

•

For other Part D vaccines, you will pay the pharmacy 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 7. For most adult Part D
vaccines, this means you will be reimbursed the entire cost you paid.

•

You will be reimbursed the amount charged by the doctor for
administering the vaccine [Only, insert the following if an out-ofnetwork differential is charged for a vaccine that is not an adult ACIPrecommended $0 cost-sharing vaccine: 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.]

CHAPTER 7:

Asking us to pay our share of a bill
you have received for covered
medical services or drugs

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

Sometimes when you get medical care or a prescription drug, you may need to pay the full cost.
Other times, you may find that you have paid more than you expected under the coverage rules
of the plan. In these cases, you can ask our plan to pay you back (paying you back is often called
reimbursing you). It is your right to be paid back by our plan whenever you’ve paid more than
your share of the cost for medical services or drugs that are covered by our plan. There may be
deadlines that you must meet to get paid back. Please see Section 2 of this chapter.
There may also be times when you get a bill from a provider for the full cost of medical care
you have received or possibly for more than your share of cost sharing as discussed in the
document. First try to resolve the bill with the provider. If that does not work, send the bill to
us instead of paying it. We will look at the bill and decide whether the services should be
covered. If we decide they should be covered, we will pay the provider directly. If we decide
not to pay it, we will notify the provider. You should never pay more than plan-allowed cost
sharing. If this provider is contracted, you still have the right to treatment.
Here are examples of situations in which you may need to ask our plan to pay you back or to pay
a bill you have received:
1. When you’ve received emergency or urgently needed medical care from a
provider who is not in our plan’s network
Outside the service area, you can receive emergency or urgently needed services from any
provider, whether or not the provider is a part of our network. In these cases,
•

You are only responsible for paying your share of the cost for emergency or urgently
needed services. Emergency providers are legally required to provide emergency care.
If you accidentally pay the entire amount yourself at the time you receive the care, ask
us to pay you back for our share of the cost. Send us the bill, along with documentation
of any payments you have made.

•

You may get a bill from the provider asking for payment that you think you do not owe.
Send us this bill, along with documentation of any payments you have already made.
o If the provider is owed anything, we will pay the provider directly.

o If you have already paid more than your share of the cost of the service, we will
determine how much you owed and pay you back for our share of the cost.

2. When a network provider sends you a bill you think you should not pay
Network providers should always bill the plan directly and ask you only for your share of the
cost. But sometimes they make mistakes and ask you to pay more than your share.
•

You only have to pay your cost-sharing amount when you get covered services. We do
not allow providers to add additional separate charges, called balance billing. This
protection (that you never pay more than your cost-sharing amount) applies even if we

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pay the provider less than the provider charges for a service and even if there is a
dispute and we don’t pay certain provider charges.
•

Whenever you get a bill from a network provider that you think is more than you
should pay, send us the bill. We will contact the provider directly and resolve the
billing problem.

•

If you have already paid a bill to a network provider, but you feel that you paid too
much, send us the bill along with documentation of any payment you have made and
ask us to pay you back the difference between the amount you paid and the amount you
owed under the plan.

3. If you are retroactively enrolled in our plan
Sometimes a person’s enrollment in the plan is retroactive. (This 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
covered services or 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 such as receipts and bills for us to
handle the reimbursement.
4. When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy, 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.
Save your receipt and send a copy to us when you ask us to pay you back for our share of the
cost. Remember that we only cover out of network pharmacies in limited circumstances. See
Chapter 5, Section 2.5 for a discussion of these circumstances.
5. 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 to look up your plan 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.
6. 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.

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140

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.

[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 9 of this document has information
about how to make an appeal.

SECTION 2

How to ask us to pay you back or to pay a bill you
have received

[Plans may edit this section to include a second address if they use different addresses for
processing medical and drug claims.]
You may request us to pay you back by [If the plan allows members to submit oral payment
requests, insert the following language: either calling us or] sending us a request in writing. If
you send a request in writing, send your bill and documentation of any payment you have made.
It’s a good idea to make a copy of your bill and receipts for your records. [Insert if applicable:
You must submit your claim to us within [insert timeframe] of the date you received the
service, item, or drug.]
[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. [Insert
the required data needed to make a decision (e.g. name, date of services, item, etc.)]

•

Either download a copy of the form from our website ([insert URL]) or call Member
Services and ask for the form.]

[Plans with different addresses for Part C and Part D claims may modify this paragraph as
needed and include the additional address] Mail your request for payment together with any
bills or paid receipts to us at this address:
[Insert address]

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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 service or 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 medical care or drug is covered and you followed all the rules, we
will pay for our share of the cost. If you have already paid for the service or drug, we will
mail your reimbursement of our share of the cost to you. If you have not paid for the
service or drug yet, we will mail the payment directly to the provider.

•

If we decide that the medical care or drug is not covered, or you did not follow all the
rules, we will not pay for our share of the cost. We will send you a letter explaining the
reasons why we are not sending the payment and your right to appeal that decision.

Section 3.2

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

If you think we have made a mistake in turning down your request for payment or 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. The appeals process is a
formal process with detailed procedures and important deadlines. For the details on how to make
this appeal, go to Chapter 9 of this document.

CHAPTER 8:

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

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SECTION 1

Our plan must honor your rights and cultural
sensitivities 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 and consistent
with your cultural sensitivities (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.]
Your plan is required to ensure that all services, both clinical and non-clinical, are provided in a
culturally competent manner and are accessible to all enrollees, including those with limited
English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and
ethnic backgrounds. Examples of how a plan may meet these accessibility requirements include,
but are not limited to: provision of translator services, interpreter services, teletypewriters, or
TTY (text telephone or teletypewriter phone) connection.
Our plan has free interpreter services available to answer questions from 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.
Our plan is required to give female enrollees the option of direct access to a women’s health
specialist within the network for women’s routine and preventive health care services.
If providers in the plan’s network for a specialty are not available, it is the plan’s responsibility
to locate specialty providers outside the network who will provide you with the necessary care.
In this case, you will only pay in-network cost sharing. If you find yourself in a situation where
there are no specialists in the plan’s network that cover a service you need, call the plan for
information on where to go to obtain this service at in-network cost sharing.
If you have any trouble getting information from our plan in a format that is accessible and
appropriate for you, seeing a women’s health specialists or finding a network specialist, 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 1-800-368-1019 or TTY 1-800-537-7697.

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We must ensure that you get timely access to your covered
services and drugs

You have the right to choose a [insert as appropriate: primary care provider (PCP) OR provider]
in the plan’s network to provide and arrange for your covered services. [Plans may edit this
sentence to add other types of providers that members may see without a referral] You also have
the right to go to a women’s health specialist (such as a gynecologist) without a referral. [If
applicable, replace previous sentence with: We do not require you to get referrals [insert if
applicable: to go to network providers].]
You have the right to get appointments and covered services from the plan’s network of
providers within a reasonable amount of time. This includes the right to get timely services from
specialists when you need that care. You also 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 medical care or Part D drugs within a reasonable
amount of time, Chapter 9 tells what you can do.
Section 1.3

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.

•

You have rights related to your 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.

•

Except for the circumstances noted below, if we intend to 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 or someone you have given legal power to make decisions
for you first.

•

There are certain exceptions that do not require us to get your written permission first.
These exceptions are allowed or required by law.
o We are required to release health information to government agencies that are
checking on quality of care.
o 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

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prescription drugs. If Medicare releases your information for research or other
uses, this will be done according to Federal statutes and regulations; typically, this
requires that information that uniquely identifies you not be shared.
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 by 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.
[Note: Plans may insert custom privacy practices.]
Section 1.4

We must give you information about the plan, its network of
providers, and your covered services

[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 2024 plan name], you have the right to get several kinds of information
from us.
If you want any of the following kinds of information, please call Member Services:
•

Information about our plan. This includes, for example, information about the plan’s
financial condition.

•

Information about our network providers and pharmacies. You have the right to get
information about the qualifications of the providers and pharmacies in our network and
how we pay the providers in our network.

•

Information about your coverage and the rules you must follow when using your
coverage. Chapters 3 and 4 provide information regarding medical services. Chapters 5
and 6 provide information about Part D prescription drug coverage.

•

Information about why something is not covered and what you can do about it.
Chapter 9 provides information on asking for a written explanation on why a medical

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service or Part D drug is not covered or if your coverage is restricted. Chapter 9 also
provides information on asking us to change a decision, also called an appeal.
Section 1.5

We must support your right to make decisions about your care

You have the right to know your treatment options and participate in decisions
about your health care
You have the right to get full information from your doctors and other health care providers.
Your providers must explain your medical condition and your treatment choices in a way that
you can understand.
You also have the right to participate fully in decisions about your health care. To help you make
decisions with your doctors about what treatment is best for you, your rights include the
following:
•

To know about all of your choices. You have the right to be told about all of the
treatment options that are recommended for your condition, no matter what they cost or
whether they are covered by our plan. It also includes being told about programs our plan
offers to help members manage their medications and use drugs safely.

•

To know about the risks. You have the right to be told about any risks involved in your
care. You must be told in advance if any proposed medical care or treatment is part of a
research experiment. You always have the choice to refuse any experimental treatments.

•

The right to say “no.” You have the right to refuse any recommended treatment. This
includes the right to leave a hospital or other medical facility, even if your doctor advises
you not to leave. You also have the right to stop taking your medication. Of course, if you
refuse treatment or stop taking medication, you accept full responsibility for what
happens to your body as a result.

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.

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The legal documents that you can use to give your directions in advance of 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. You can get an advance directive 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.]

•

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 who can make decisions for you if you can’t.
You may want to give copies to close friends or family members. 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.
•

The hospital 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 refer to that exhibit.]
Section 1.6

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

If you have any problems, concerns, or complaints and need to request coverage, or make an
appeal, Chapter 9 of this document tells what you can do. Whatever you do – ask for a coverage
decision, make an appeal, or make a complaint – we are required to treat you fairly.

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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, sexual orientation, 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.

•

You can call the SHIP. For details, 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 1-877-486-2048).

Section 1.8

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.

•

You can call the SHIP. For details, go to Chapter 2, Section 3.

•

You can contact Medicare.
o You can visit the Medicare website to read or download the publication Medicare
Rights & Protections. (The publication is available at:
www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)
o Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week (TTY 1-877-486-2048).

SECTION 2

You have some responsibilities as a member of the
plan

Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services.
•

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

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o Chapters 3 and 4 give the details about your medical services.

o Chapters 5 and 6 give the details about your Part D prescription drug coverage.

•

If you have any other health insurance coverage or prescription drug coverage in
addition to our plan, you are required to tell us. Chapter 1 tells you about coordinating
these benefits.

•

Tell your doctor and other health care providers that you are enrolled in our plan.
Show your plan membership card whenever you get your medical care or Part D
prescription drugs.

•

Help your doctors and other providers help you by giving them information, asking
questions, and following through on your care.
o To help get the best care, tell your doctors and other health providers about your
health problems. Follow the treatment plans and instructions that you and your
doctors agree upon.
o Make sure your doctors know all of the drugs you are taking, including over-thecounter drugs, vitamins, and supplements.
o If you have any questions, be sure to ask and get an answer you can understand.

•

Be considerate. We expect all our members to respect the rights of other patients. We
also expect you to act in a way that helps the smooth running of your doctor’s office,
hospitals, and other offices.

•

Pay what you owe. As a plan member, you are responsible for these payments:
o [Insert if applicable: You must pay your plan premiums.]

o You must continue to pay a premium for your Medicare Part B to remain a
member of the plan.
o For most of your medical services or drugs covered by the plan, you must pay
your share of the cost when you get the service or drug.
[Plans that do not disenroll members for non-payment may modify this section as needed.]
o [Plans offering Part D, insert: If you are required to pay a late enrollment penalty,
you must pay the penalty to keep your prescription drug coverage.]
o If you are required to pay the extra amount for Part D because of your yearly
income, you must continue to pay the extra amount directly to the government to
remain a member of the plan.
•

If you move within our service area, we need to know so we can keep your
membership record up to date and know how to contact you.

•

If you move outside of our plan service area, you [if a continuation area is offered,
insert: generally here and then explain the continuation area] cannot remain a member
of our plan.

•

If you move, it is also important to tell Social Security (or the Railroad Retirement
Board).

CHAPTER 9:

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

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

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 problems, you need to use the process for coverage decisions and appeals.

•

For other problems, you need to use the process for making complaints; also called
grievances.

Both of these processes have been approved by Medicare. Each process has a set of rules,
procedures, and deadlines that must be followed by us and by you.
The guide in Section 3 will help you identify the right process to use and what you should do.
Section 1.2

What about the legal terms?

There are 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
make things easier, this chapter:
•

•

Uses 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
organization determination, or coverage determination or at-risk 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. Knowing which terms to use will help you communicate more accurately to 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

Where to get more information and personalized
assistance

We are always available to help you. Even if you have a complaint about our treatment of you,
we are obligated to honor your right to complain. Therefore, you should always reach out to

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customer service for help. But in some situations, you may also want help or guidance from
someone who is not connected with us. Below are two entities that can assist you.
State Health Insurance Assistance Program (SHIP)
Each state has a government program with trained counselors. 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
and website URLs in Chapter 2, Section 3 of this document.
Medicare
You can also contact Medicare to get help. To contact 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 also visit the Medicare website (www.medicare.gov).

SECTION 3

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

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.

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Is your problem or concern about your benefits or coverage?
This includes problems about whether medical care or prescription drugs are covered or not,
the way they are covered, and problems related to payment for medical care or prescription
drugs.
Yes.
Go on to the next section of this chapter, Section 4, A guide to the basics of
coverage decisions and appeals.
No.
Skip ahead to Section 10 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

Coverage decisions and appeals deal with problems related to your benefits and coverage for
medical services and prescription drugs, including payment. This is the process you use for
issues such as whether something is covered or not and the way in which something is covered.
Asking for coverage decisions prior to receiving benefits
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your medical services or drugs. For example, if your plan network doctor refers
you to a medical specialist not inside the network, this referral is considered a favorable coverage
decision unless either your network doctor can show that you received a standard denial notice
for this medical specialist, or the Evidence of Coverage makes it clear that the referred service is
never covered under any condition. You or your doctor can also contact us and ask for a
coverage decision if your doctor is unsure whether we will cover a particular medical service or
refuses to provide medical care you think that you need. In other words, if you want to know if
we will cover a medical service before you receive it, you can ask us to make a coverage
decision for you. In limited circumstances a request for a coverage decision will be dismissed,
which means we won’t review the request. Examples of when a request will be dismissed include

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if the request is incomplete, if someone makes the request on your behalf but isn’t legally
authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a
coverage decision, we will send a notice explaining why the request was dismissed and how to
ask for a review of the dismissal.
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 service or 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, whether before or after a benefit is received, and you are not
satisfied, you can appeal the decision. An appeal is a formal way of asking us to review and
change a coverage decision we have made. Under certain circumstances, which we discuss later,
you can request an expedited or fast appeal of a coverage decision. Your appeal is handled by
different reviewers than those who made the original decision.
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 properly following the rules.
When we have completed the review, we give you our decision.
In limited circumstances a request for a Level 1 appeal will be dismissed, which means we won’t
review the request. Examples of when a request will be dismissed include if the request is
incomplete, if someone makes the request on your behalf but isn’t legally authorized to do so or
if you ask for your request to be withdrawn. If we dismiss a request for a Level 1 appeal, we will
send a notice explaining why the request was dismissed and how to ask for a review of the
dismissal.
If we say no to all or part of your Level 1 appeal for medical services and Part B drugs, your
appeal with automatically go on to a Level 2 appeal conducted by an independent review
organization that is not connected to us.
•

You do not need to do anything to start a Level 2 appeal. Medicare rules require we
automatically send your appeal for medical services and Part B drugs to Level 2 if we do
not fully agree with your Level 1 appeal.

•

See Section 6.4 of this chapter for more information about Level 2 appeals.

•

For Part D drug appeals, if we say no to all or part of your appeal, you will need to ask
for a Level 2 appeal. Part D appeals are discussed further in Section 7 of this chapter.

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 9 in this chapter explains the Level 3, 4, and 5
appeals processes).

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

Here are resources if you decide to ask for any kind of coverage decision or appeal a decision:
•

You can call us at Member Services.

•

You can get free help from your State Health Insurance Assistance Program.

•

Your doctor can make a request for you. If your doctor helps with an appeal past Level
2, they will need to be appointed as your representative. Please call Member Services and
ask for the Appointment of Representative form. (The form is also available on
Medicare’s website at www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms1696.pdf [plans may also insert: or on our website at [insert
website or link to form]].)
o For medical care or Part B prescription drugs, your doctor can request a coverage
decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it
will be automatically forwarded to Level 2.
o For Part D prescription drugs, your doctor or other prescriber can request a
coverage decision or a Level 1 appeal on your behalf. If your Level 1 appeal is
denied your doctor or prescriber can request a Level 2 appeal.

•

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.
o If you want a friend, relative, or other person to be your representative, call
Member Services and ask for the Appointment of Representative form. (The form
is also available on Medicare’s website at www.cms.gov/Medicare/CMSForms/CMS-Forms/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.
o While we can accept an appeal request without the form, we cannot begin or
complete our review until we receive it. If we do not receive the form within 44
calendar days after receiving your appeal request (our deadline for making a
decision on your appeal), your appeal request will be dismissed. If this happens,
we will send you a written notice explaining your right to ask the independent
review organization to review our decision to dismiss your appeal.

•

You also have the right to hire a lawyer. 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.

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Which section of this chapter gives the details for your
situation?

There are four different situations that involve coverage decisions and appeals. Since each
situation has different rules and deadlines, we give the details for each one in a separate section:
•

Section 5 of this chapter: “Your medical care: How to ask for a coverage decision or
make an appeal”

•

Section 6 of this chapter: “Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal”

•

Section 7 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you
think the doctor is discharging you too soon”

•

Section 8 of this chapter: “How to ask us to keep covering certain medical services if you
think your coverage is ending too soon” (Applies only to these services: home health
care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility
(CORF) services)

If you’re not sure which section you should be using, please call Member Services. You can also
get help or information from government organizations such as your SHIP.

SECTION 5

Your medical care: How to ask for a coverage
decision or make an appeal of a coverage decision

Section 5.1

This section tells what to do if you have problems getting
coverage for medical care or if you want us to pay you back
for our share of the cost of your care

This section is about your benefits for medical care and services. These benefits are described in
Chapter 4 of this document: Medical Benefits Chart (what is covered and what you pay). To
keep things simple, we generally refer to medical care coverage or medical care which includes
medical items and services as well as Medicare Part B prescription drugs. In some cases,
different rules apply to a request for a Part B prescription drug. In those cases, we will explain
how the rules for Part B prescription drugs are different from the rules for medical items and
services.
This section tells what you can do if you are in any of the five following situations:
1. You are not getting certain medical care you want, and you believe that this care is
covered by our plan. Ask for a coverage decision. Section 5.2.
2. Our plan will not approve the medical care your doctor or other medical provider wants
to give you, and you believe that this care is covered by the plan. Ask for a coverage
decision. Section 5.2.

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3. You have received medical care that you believe should be covered by the plan, but we
have said we will not pay for this care. Make an appeal. Section 5.3.
4. You have received and paid for medical care that you believe should be covered by the
plan, and you want to ask our plan to reimburse you for this care. Send us the bill.
Section 5.5.
5. You are being told that coverage for certain medical care you have been getting that we
previously approved will be reduced or stopped, and you believe that reducing or
stopping this care could harm your health. Make an appeal. Section 5.3.
Note: If the coverage that will be stopped is for hospital care, home health care,
skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility
(CORF) services, you need to read Sections 7 and 8 of this Chapter. Special rules apply
to these types of care.
Section 5.2

Step-by-step: How to ask for a coverage decision
Legal Terms

When a coverage decision involves your medical care, it is called an organization
determination.
A fast coverage decision is called an expedited determination.
Step 1: Decide if you need a standard coverage decision or a fast coverage
decision.
A standard coverage decision is usually made within 14 days or 72 hours for Part B
drugs. A fast coverage decision is generally made within 72 hours, for medical services,
or 24 hours for Part B drugs. In order to get a fast coverage decision, you must meet two
requirements:
•

You may only ask for coverage for medical care you have not yet received.

•

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 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
support, we will decide whether your health requires that we give you a fast
coverage decision. If we do not approve a fast coverage decision, we will send you a
letter that:
o Explains that we will use the standard deadlines.
o Explains if your doctor asks for the fast coverage decision, we will
automatically give you a fast coverage decision.

•

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o Explains that you can file a fast complaint about our decision to give you a
standard coverage decision instead of the fast coverage decision you
requested.
Step 2: Ask our plan to make a coverage decision or fast coverage decision.
•

Start by calling, writing, or faxing our plan to make your request for us to
authorize or provide coverage for the medical care you want. You, your doctor, or
your representative can do this. Chapter 2 has contact information.

Step 3: We consider your request for medical care coverage and give you our
answer.
For standard coverage decisions we use the standard deadlines.
This means we will give you an answer within 14 calendar days after we receive your request
for a medical item or service. If your request is for a Medicare Part B prescription drug, we
will give you an answer within 72 hours after we receive your request.
•

However, if you ask for more time, or if we need more information that may benefit
you we can take up to 14 more days if your request is for a medical item or service.
If we take extra days, we will tell you in writing. We can’t take extra time to make a
decision if your request is for a Medicare Part B prescription drug.

•

If you believe we should not take extra days, you can file a fast complaint. We will
give you an answer to your complaint as soon as we make the decision. (The
process for making a complaint is different from the process for coverage
decisions and appeals. See Section 10 of this chapter for information on
complaints.)

For Fast Coverage decisions we use an expedited timeframe
A fast coverage decision means we will answer within 72 hours if your request is for a
medical item or service. If your request is for a Medicare Part B prescription drug, we will
answer within 24 hours.
•

However, if you ask for more time, or if we need more that may benefit you, we can
take up to 14 more days. If we take extra days, we will tell you in writing. We can’t
take extra time to make a decision if your request is for a Medicare Part B
prescription drug.

•

If you believe we should not take extra days, you can file a fast complaint. (See
Section 10 of this chapter for information on complaints.) We will call you as soon
as we make the decision.

•

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.

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Step 4: If we say no to your request for coverage for medical care, you can
appeal.
•

If we say no, you have the right to ask us to reconsider this decision by making an
appeal. This means asking again to get the medical care coverage you want. If you
make an appeal, it means you are going on to Level 1 of the appeals process.

Section 5.3

Step-by-step: How to make a Level 1 appeal
Legal Terms

An appeal to the plan about a medical care coverage decision is called a plan reconsideration.
A fast appeal is also called an expedited reconsideration.
Step 1: Decide if you need a standard appeal or a fast appeal.
A standard appeal is usually made within 30 days or 7 days for Part B drugs. A fast
appeal is generally made within 72 hours.
•

If you are appealing a decision, we made about coverage for care that you have not
yet received, you and/or your doctor will need to decide if you need a fast appeal. If
your doctor tells us that your health requires a fast appeal, we will give you a fast
appeal.

•

The requirements for getting a fast appeal are the same as those for getting a fast
coverage decision in Section 5.2 of this chapter.

Step 2: Ask our plan for an appeal or a Fast appeal
•

If you are asking for a standard appeal, submit your standard appeal in
writing. [If the plan accepts oral requests for standard appeals, insert: You may
also ask for an appeal by calling us.] Chapter 2 has contact information.

•

If you are asking for a fast appeal, make your appeal in writing or call us.
Chapter 2 has contact information.

•

You must make your appeal request within 60 calendar days from the date on
the written notice we sent to tell you our answer on the coverage decision. If you
miss this deadline and have a good reason for missing it, explain the reason your
appeal is late when you make your appeal. We may give you more time to make
your appeal. Examples of good cause may include 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 regarding your medical decision.
You and your doctor may add more information to support your appeal. [If a
fee is charged, insert: We are allowed to charge a fee for copying and sending this
information to you.]

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Step 3: We consider your appeal and we give you our answer.
•

When our plan is reviewing your appeal, we take a careful look at all of the
information. We check to see if we were following all the rules when we said no to
your request.

•

We will gather more information if needed possibly contacting you or your doctor.

Deadlines for a fast appeal
•

•
•

For fast appeals, 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 us to.
o However, if you ask for more time, or if we need more information that may
benefit you, we can take up to 14 more calendar days if your request is for a
medical item or service. If we take extra days, we will tell you in writing. We
can’t take extra time if your request is for a Medicare Part B prescription drug.
o If we do not give you an answer within 72 hours (or by the end of the extended
time period if we took extra days), we are required to automatically send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent review organization. Section 5.4 explains the Level 2 appeal process.
If our answer is yes to part or all of what you requested, we must authorize or
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 our
decision in writing and automatically forward your appeal to the independent review
organization for a Level 2 appeal. The independent review organization will notify
you in writing when it receives your appeal.

Deadlines for a standard appeal
•

For standard appeals, we must give you our answer within 30 calendar days after we
receive your appeal. If your request is for a Medicare Part B prescription drug you
have not yet received, we will give you our answer within 7 calendar days after we
receive your appeal. We will give you our decision sooner if your health condition
requires us to.
o However, if you ask for more time, or if we need more information that may
benefit you, we can take up to 14 more calendar days if your request is for a
medical item or service. If we take extra days, we will tell you in writing. We
can’t take extra time to make a decision if your request is for a Medicare Part B
prescription drug.
o If you believe we should not take extra days, you can file a fast complaint. When
you file a fast complaint, we will give you an answer to your complaint within 24
hours. (See Section 10 of this chapter for information on complaints.)
o If we do not give you an answer by the deadline (or by the end of the extended
time period), we will send your request to a Level 2 appeal, where an independent
review organization will review the appeal. Section 5.4 explains the Level 2
appeal process.

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If our answer is yes to part or all of what you requested, we must authorize or
provide the coverage within 30 calendar days if your request is for a medical item
or service, or within 7 calendar days if your request is for a Medicare Part B
prescription drug.
If our plan says no to part or all of your appeal, we will automatically send your
appeal to the independent review organization for a Level 2 appeal.

Section 5.4

Step-by-step: How a Level 2 appeal is done
Legal Term

The formal name for the independent review organization is the Independent Review Entity.
It is sometimes called the IRE.
The independent review organization is an independent organization hired by Medicare. It
is not connected with us and is not a government agency. This organization decides whether the
decision we made is correct or if it should be changed. Medicare oversees its work.
Step 1: The independent review organization reviews your appeal.
•

We will send the information 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.

•

Reviewers at the independent review organization will take a careful look at all of the
information related to your appeal.

If you had a fast appeal at Level 1, you will also have a fast appeal at Level 2
•

For the fast appeal, the review organization must give you an answer to your Level 2
appeal within 72 hours of when it receives your appeal.

•

However, if your request is for a medical item or service and the independent review
organization needs to gather more information that may benefit you, it can take up to
14 more calendar days. The independent review organization can’t take extra time
to make a decision if your request is for a Medicare Part B prescription drug.

If you had a standard appeal at Level 1, you will also have a standard appeal at Level 2
•

For the standard appeal if your request is for a medical item or service, the review
organization must give you an answer to your Level 2 appeal within 30 calendar
days of when it receives your appeal. If your request is for a Medicare Part B
prescription drug, the review organization must give you an answer to your Level 2
appeal within 7 calendar days of when it receives your appeal.

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Step 2: The independent review organization gives you their answer.
The independent review organization will tell you its decision in writing and explain the
reasons for it.
•

If the review organization says yes to part or all of a request for a medical item
or service, we must authorize the medical care coverage within 72 hours or provide
the service within 14 calendar days after we receive the decision from the review
organization for standard requests. For expedited requests, we have 72 hours from the
date we receive the decision from the review organization.

•

If the review organization says yes to part or all of a request for a Medicare Part
B prescription drug, we must authorize or provide the Part B prescription drug
within 72 hours after we receive the decision from the review organization for
standard requests. For expedited requests we have 24 hours from the date we
receive the decision from the review organization.

•

If this organization says no to part or all of your appeal, it means they agree with
us that your request (or part of your request) for coverage for medical care should not
be approved. (This is called upholding the decision or turning down your appeal.).
In this case, the independent review organization will send you a letter:
o Explaining its decision.

o Notifying you of the right to a Level 3 appeal if the dollar value of the medical
care coverage meets a certain minimum. The written notice you get from the
independent review organization will tell you the dollar amount you must meet to
continue the appeals process.
o Telling you how to file a Level 3 appeal.
Step 3: If your case meets the requirements, 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 you want to go to a Level 3 appeal the details on how to do
this are in the written notice you get after your Level 2 appeal.

•

The Level 3 appeal is handled by an Administrative Law Judge or attorney
adjudicator. Section 9 in this chapter explains the Level 3, 4, and 5 appeals processes.

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What if you are asking us to pay you for our share of a bill you
have received for medical care?

Chapter 7 describes when you may need to ask for reimbursement or to pay a bill you have
received from a provider. It also tells how to send us the paperwork that asks us for payment.
Asking for reimbursement is asking for a coverage decision from us
If you send us the paperwork asking for reimbursement, you are asking for a coverage decision.
To make this decision, we will check to see if the medical care you paid for is a covered service.
We will also check to see if you followed all the rules for using your coverage for medical care.
•

If we say yes to your request: If the medical care is covered and you followed all the
rules, we will send you the payment for our share of the cost within 60 calendar days
after we receive your request. If you haven’t paid for the services, we will send the
payment directly to the provider.

•

If we say no to your request: If the medical care is not covered, or you did not follow all
the rules, we will not send payment. Instead, we will send you a letter that says we will
not pay for the services and the reasons why.

If you do not agree with our decision to turn you down, you can make an appeal. If you make
an appeal, it means you are asking us to change the coverage decision we made when we turned
down your request for payment.
To make this appeal, follow the process for appeals that we describe in Section 5.3. For
appeals concerning reimbursement, please note:
•

We must give you our answer within 60 calendar days after we receive your appeal. If
you are asking us to pay you back for medical care you have already received and paid
for, you are not allowed to ask for a fast appeal.

•

If the independent review organization decides we should pay, we must send you or the
provider the payment within 30 calendar days. If the answer to your appeal is yes at any
stage of the appeals process after Level 2, we must send the payment you requested to
you or to the provider within 60 calendar days.

SECTION 6

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

Section 6.1

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 include coverage for many prescription drugs. To be covered, the drug must be
used for a medically accepted indication. (See Chapter 5 for more information about a medically

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accepted indication.) For details about Part D drugs, rules, restrictions, and costs please see
Chapters 5 and 6. 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. We also use the term “Drug list” instead of List of Covered
Drugs or Formulary.
•

If you do not know if a drug is covered or if you meet the rules, you can ask us. Some
drugs require that you get approval from us before we will cover it.

•

If your pharmacy tells you that your prescription cannot be filled as written, the
pharmacy will give you a written notice explaining how to contact us to ask for a
coverage decision.

Part D coverage decisions and appeals
Legal Term
An initial coverage decision about your Part D drugs is called a coverage determination.
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your drugs. This section tells what you can do if you are in any of the following
situations:
•

Asking to cover a Part D drug that is not on the plan’s List of Covered Drugs. Ask for an
exception. Section 6.2

•

Asking to waive a restriction on the plan’s coverage for a drug (such as limits on the
amount of the drug you can get). Ask for an exception. Section 6.2

•

[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. Ask for an exception. Section 6.2

•

Asking to get pre-approval for a drug. Ask for a coverage decision. Section 6.4

•

Pay for a prescription drug you already bought. Ask us to pay you back. Section 6.4

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.

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What is an exception?
Legal Terms

Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a
formulary exception.
Asking for removal of a restriction on coverage for a drug is sometimes called asking for a
formulary exception.
Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a
tiering 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.
For us to consider your exception request, your doctor or other prescriber will need to explain the
medical reasons why you need the exception approved. 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 Drug List. If we agree to cover a
drug 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 cost-sharing amount we require you to pay
for the drug.
2. Removing a restriction for a covered drug. Chapter 5 describes the extra rules or
restrictions that apply to certain drugs on our “Drug List.” [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.
•

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).

•

[Plans that have a formulary structure where all of the biological products are on
one tier or that do not limit their tiering exceptions in this way: omit this bullet] If the
drug you’re taking is a biological product you can ask us to cover your drug at a

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lower cost-sharing amount. This would be the lowest tier that contains biological
product alternatives for treating your condition.
•

[Plans that do not limit their tiering exceptions in this way; omit this bullet] If the
drug you’re taking is a brand name drug you can ask us to cover your drug at the costsharing amount that applies to the lowest tier that contains brand name alternatives
for treating your condition.

•

[Plans that do not limit their tiering exceptions in this way; omit this bullet] If the
drug you’re taking is a generic drug you can ask us to cover your drug at the costsharing amount that applies to the lowest tier that contains either brand or generic
alternatives for treating your condition.

•

[If the plan designated one of its tiers as a specialty 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].]

•

If we approve your tiering exception request and there is more than one lower costsharing tier with alternative drugs you can’t take, you will usually pay the lowest
amount.

Section 6.3

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 or are likely to
cause an adverse reaction or other harm.
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, you can ask for another review by making an appeal.

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Step-by-step: How to ask for a coverage decision, including an
exception
Legal Term

A fast coverage decision is called an expedited coverage determination.
Step 1: Decide if you need a standard coverage decision or a fast coverage
decision.
Standard coverage decisions are made within 72 hours after we receive your doctor’s
statement. Fast coverage decisions are made within 24 hours after we receive your doctor’s
statement.
If your health requires it, ask us to give you a fast coverage decision. To get a fast coverage
decision, you must meet two requirements:
•

You must be asking for a drug you have not yet received. (You cannot ask for fast
coverage decision to be paid back for a drug you have already bought.)

•

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 give you a fast coverage decision.

•

If you ask for a fast coverage decision on your own, without your doctor or
prescriber’s support, we will decide whether your health requires that we give you a
fast coverage decision. If we do not approve a fast coverage decision, we will send you a
letter that:
o Explains that we will use the standard deadlines.

o Explains if your doctor or other prescriber asks for the fast coverage decision, we
will automatically give you a fast coverage decision.

o Tells you how you can file a fast complaint about our decision to give you a
standard coverage decision instead of the fast coverage decision you requested.
We will answer your complaint within 24 hours of receipt.
Step 2: Request a standard coverage decision or a fast coverage decision.
Start by calling, writing, or faxing our plan to make your request for us to authorize or provide
coverage for the medical care you want. You can also access the coverage decision process
through our website. 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. Chapter 2 has contact
information. [Plans that allow members to submit coverage determination requests
electronically through, for example, a secure member portal may include a brief description of

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that process.] To assist us in processing your request, please be sure to include your name,
contact information, and information identifying which denied claim is being appealed.
You, your doctor (or other prescriber), or your representative can do this. You can also have a
lawyer act on your behalf. Section 4 of this chapter tells how you can give written permission
to someone else to act as your representative.
•

If you are requesting an exception, provide the supporting statement which is the
medical reasons for the exception. 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.

Step 3: We consider your request and give you our answer.
Deadlines for a fast coverage decision
•

We must generally give you our answer within 24 hours after we receive your request.
o For exceptions, we will give you our answer within 24 hours after we receive
your doctor’s supporting statement. We will give you our answer sooner if your
health requires us to.
o If we do not meet this deadline, we are required to send your request to Level 2 of
the appeals process, where it will be reviewed by an independent review
organization.

•

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 you can appeal.

Deadlines for a standard coverage decision about a drug you have not yet received
•

We must generally give you our answer within 72 hours after we receive your request.
o For exceptions, we will give you our answer within 72 hours after we receive
your doctor’s supporting statement. We will give you our answer sooner if your
health requires us to.
o 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 review
organization.

•

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 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 you can appeal.

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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.
o If we do not meet this deadline, we are required to send your request to Level 2 of
the appeals process, where it will be reviewed by an independent review
organization.

•

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 you can appeal.

Step 4: If we say no to your coverage request, you can make an appeal.
•

If we say no, you have the right to ask us to reconsider this decision by making an appeal.
This means asking again to get the drug coverage you want. If you make an appeal, it
means you are going to Level 1 of the appeals process.

Section 6.5

Step-by-step: How to make a Level 1 appeal
Legal Terms

An appeal to the plan about a Part D drug coverage decision is called a plan redetermination.
A fast appeal is also called an expedited redetermination.
Step 1: Decide if you need a standard appeal or a fast appeal.
A standard appeal is usually made within 7 days. A fast appeal is generally made within 72
hours. If your health requires it, ask for a fast appeal.
•

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 6.4 of this chapter.

Step 2: You, your representative, doctor, or other prescriber must contact us and
make your Level 1 appeal. If your health requires a quick response, you must ask for a
fast appeal.
•

For standard appeals, submit a written request. [If the plan accepts oral requests for
standard appeals, insert: or call us]. Chapter 2 has contact information.

•

For fast appeals either submit your appeal in writing or call us at (insert phone
number). Chapter 2 has contact information.

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•

We must accept any written request, including a request submitted on the CMS Model
Coverage Determination Request Form, which is available on our website. Please be sure
to include your name, contact information, and information regarding your claim to assist
us in processing your request.

•

[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 on the coverage decision. If you miss this
deadline and have a good reason for missing it, explain the reason your appeal is late
when you make your appeal. We may give you more time to make your appeal.
Examples of good cause may include 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 and your doctor may add more information to support your appeal. [If
a fee is charged, insert: We are allowed to charge a fee for copying and sending this
information to you.]

Step 3: 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
•

For fast appeals, 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 us to.
o 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. Section 6.6 explains the Level 2 appeal 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 you can appeal our decision.

Deadlines for a standard appeal for a drug you have not yet received
•

For standard appeals, 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.
o 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. Section 6.6 explains the Level 2 appeal process.

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•

If our answer is yes to part or all of what you requested, we must provide the
coverage as quickly as your health requires, but no later than 7 calendar days 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 you can appeal our decision.

Deadlines for a standard appeal about payment for a drug you have already bought
•

•

If our answer is yes to part or all of what you requested, we are also required to make
payment to you within 30 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 you can appeal.

Step 4: If we say no to your appeal, you decide if you want to continue with the
appeals process and make another appeal.
•

If you decide to make another appeal, it means your appeal is going on to Level 2 of the
appeals process.

Section 6.6

Step-by-step: How to make a Level 2 appeal
Legal Term

The formal name for the independent review organization is the Independent Review Entity.
It is sometimes called the IRE.
The independent review organization is an independent organization hired by
Medicare. It is not connected with us and is not a government agency. This organization
decides whether the decision we made is correct or if it should be changed. Medicare
oversees its work.
Step 1: 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. If, however, we did
not complete our review within the applicable timeframe, or make an unfavorable
decision regarding at-risk determination under our drug management program, we will
automatically forward your claim to the IRE.

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•

We will send the information 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 reviews your appeal.
Reviewers at the independent review organization will take a careful look at all of the
information related to your appeal.
Deadlines for fast appeal
•

If your health requires it, ask the independent review organization for a fast appeal.

•

If the organization agrees to give you a fast appeal, the organization must give you an
answer to your Level 2 appeal within 72 hours after it receives your appeal request.

Deadlines for standard appeal
•

For standard appeals, the review organization must give you an answer to your Level 2
appeal within 7 calendar days after it receives your appeal if it is for a drug you have
not yet received. If you are requesting that we pay you back for a drug you have already
bought, the review organization must give you an answer to your Level 2 appeal within
14 calendar days after it receives your request.

Step 3: The independent review organization gives you their answer.
For fast appeals:
•

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.

For standard appeals:
•

If the independent review organization says yes to part or all of your 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 says yes to part or all of your 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 part or all of your appeal, it means they agree with our decision
not to approve your request (or part of your request). (This is called upholding the decision. It is

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also called turning down your appeal.). In this case, the independent review organization will
send you a letter:
•
•

•

Explaining its decision.
Notifying you of the right to a Level 3 appeal if the dollar value of the drug coverage you
are requesting meets a certain minimum. 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.
Telling you the dollar value that must be in dispute to continue with the appeals process.

Step 4: If your case meets the requirements, 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 you want to go on to a Level 3 appeal the details on how to do this are in the written
notice you get after your Level 2 appeal decision.

•

The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator.
Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 7

How to ask us to cover a longer inpatient hospital
stay if you think the doctor is discharging you too
soon

When you are admitted to a hospital, you have the right to get all of your covered hospital
services that are necessary to diagnose and treat your illness or injury.
During your covered hospital stay, your doctor and the hospital staff will be working with you to
prepare for the day when you will leave the hospital. They will help arrange for care you may
need after you leave.
•

The day you leave the hospital is called your discharge date.

•

When your discharge date is decided, your doctor or the hospital staff will tell you.

•

If you think you are being asked to leave the hospital too soon, you can ask for a longer
hospital stay, and your request will be considered.

Section 7.1

During your inpatient hospital stay, you will get a written
notice from Medicare that tells about your rights

Within two days of being admitted to the hospital, you will be given a written notice called An
Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of
this notice If you do not get the notice from someone at the hospital (for example, a caseworker

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or nurse), ask any hospital employee for it. If you need help, please call Member Services or 1800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).
1. Read this notice carefully and ask questions if you don’t understand it. It tells you:
•

Your right to receive Medicare-covered services during and after your hospital stay,
as ordered by your doctor. This includes the right to know what these services are,
who will pay for them, and where you can get them.

•

Your right to be involved in any decisions about your hospital stay.

•

Where to report any concerns you have about the quality of your hospital care.

•

Your right to request an immediate review of the decision to discharge you if you
think you are being discharged from the hospital too soon. This is a formal, legal way
to ask for a delay in your discharge date so that we will cover your hospital care for a
longer time.

2. You will be asked to sign the written notice to show that you received it and
understand your rights.
•

You or someone who is acting on your behalf will be asked to sign the notice.

•

Signing the notice shows only that you have received the information about your
rights. The notice does not give your discharge date. Signing the notice does not
mean you are agreeing on a discharge date.

3. Keep your copy of the notice handy so you will have the information about making an
appeal (or reporting a concern about quality of care) if you need it.
•

If you sign the notice more than two days before your discharge date, you will get
another copy before you are scheduled to be discharged.

•

To look at a copy of this notice in advance, you can call Member Services or 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 also see the notice online at
www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/HospitalDischargeAppealNotices.

Section 7.2

Step-by-step: How to make a Level 1 appeal to change your
hospital discharge date

If you want to ask for your inpatient hospital services to be covered by us for a longer time, you
will need to use the appeals process to make this request. Before you start, understand what you
need to do and what the deadlines are.
•

Follow the process.

•

Meet the deadlines.

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Ask for help if you need it. If you have questions or need help at any time, please call
Member Services. Or call your State Health Insurance Assistance Program, a government
organization that provides personalized assistance.

During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It
checks to see if your planned discharge date is medically appropriate for you.
The Quality Improvement Organization is a group of doctors and other health care
professionals paid by the Federal government to check on and help improve the quality of care
for people with Medicare. This includes reviewing hospital discharge dates for people with
Medicare. These experts are not part of our plan.
Step 1: Contact the Quality Improvement Organization for your state and ask for
an immediate review of your hospital discharge. You must act quickly.
How can you contact this organization?
•

The written notice you received (An Important Message from Medicare About Your
Rights) tells you how to reach this organization. Or find the name, address, and phone
number of the Quality Improvement Organization for your state in Chapter 2.

Act quickly:
•

To make your appeal, you must contact the Quality Improvement Organization before
you leave the hospital and no later than midnight the day of your discharge.
o If you meet this deadline, you may stay in the hospital after your discharge date
without paying for it while you wait to get the decision from the Quality
Improvement Organization.
o If you do not meet this deadline, and you decide to stay in the hospital after your
planned discharge date, you may have to pay all of the costs for hospital care you
receive after your planned discharge date.

•

If you miss the deadline for contacting the Quality Improvement Organization, and you
still wish to appeal, you must make an appeal directly to our plan instead. For details
about this other way to make your appeal, see Section 7.4.

Once you request an immediate review of your hospital discharge the Quality Improvement
Organization will contact us. By noon of the day after we are contacted, we will give you a
Detailed Notice of Discharge. This notice gives your planned discharge date and explains in
detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate)
for you to be discharged on that date.
You can get a sample of the Detailed Notice of Discharge by calling Member Services or 1800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1877-486-2048.) Or you can see a sample notice online at www.cms.gov/Medicare/MedicareGeneral-Information/BNI/HospitalDischargeAppealNotices.

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Step 2: The Quality Improvement Organization conducts an independent review
of your case.
•

Health professionals at the Quality Improvement Organization (the reviewers) will ask
you (or your representative) why you believe coverage for the services should continue.
You don’t have to prepare anything in writing, but you may do so if you wish.

•

The reviewers will also look at your medical information, talk with your doctor, and
review information that the hospital and we have given to them.

•

By noon of the day after the reviewers told us of your appeal, you will get a written
notice from us that gives your planned discharge date. This notice also explains in detail
the reasons why your doctor, the hospital, and we think it is right (medically appropriate)
for you to be discharged on that date.

Step 3: Within one full day after it has all the needed information, the Quality
Improvement Organization will give you its answer to your appeal.
What happens if the answer is yes?
•

If the review organization says yes, we must keep providing your covered inpatient
hospital services for as long as these services are medically necessary.

•

You will have to keep paying your share of the costs (such as deductibles or copayments
if these apply). In addition, there may be limitations on your covered hospital services.

What happens if the answer is no?
•

If the review organization says no, they are saying that your planned discharge date is
medically appropriate. If this happens, our coverage for your inpatient hospital
services will end at noon on the day after the Quality Improvement Organization gives
you its answer to your appeal.

•

If the review organization says no to your appeal and you decide to stay in the hospital,
then you may have to pay the full cost of hospital care you receive after noon on the day
after the Quality Improvement Organization gives you its answer to your appeal.

Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make
another appeal.
•

If the Quality Improvement Organization has said no to your appeal, and you stay in the
hospital after your planned discharge date, then you can make another appeal. Making
another appeal means you are going on to Level 2 of the appeals process.

Section 7.3

Step-by-step: How to make a Level 2 appeal to change your
hospital discharge date

During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at
their decision on your first appeal. If the Quality Improvement Organization turns down your
Level 2 appeal, you may have to pay the full cost for your stay after your planned discharge date.

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Step 1: Contact the Quality Improvement Organization again and ask for another
review.
•

You must ask for this review within 60 calendar days after the day the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this review
only if you stay in the hospital after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your
situation.
•

Reviewers at the Quality Improvement Organization will take another careful look at all
of the information related to your appeal.

Step 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the
reviewers will decide on your appeal and tell you their decision.
If the review organization says yes:
•

We must reimburse you for our share of the costs of hospital care you have received
since noon on the day after the date your first appeal was turned down by the Quality
Improvement Organization. We must continue providing coverage for your inpatient
hospital care for as long as it is medically necessary.

•

You must continue to pay your share of the costs and coverage limitations may apply.

If the review organization says no:
•

It means they agree with the decision they made on your Level 1 appeal. This is called
upholding the decision.

•

The notice you get will tell you in writing what you can do if you wish to continue with
the review process.

Step 4: If the answer is no, you will need to decide whether you want to take your
appeal further by going on to Level 3.
•

There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are
in the written notice you get after your Level 2 appeal decision.

•

The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator.
Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Section 7.4

What if you miss the deadline for making your Level 1 appeal
to change your hospital discharge date?
Legal Term

A fast review (or fast appeal) is also called an expedited appeal.

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You can appeal to us instead
As explained above, you must act quickly to start your Level 1 appeal of your hospital discharge
date. If you miss the deadline for contacting the Quality Improvement Organization, there is
another way to make your appeal.
If you use this other way of making your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate appeal
Step 1: Contact us and ask for a fast review.
•

Ask for a fast review. This means you are asking us to give you an answer using the fast
deadlines rather than the standard deadlines. Chapter 2 has contact information.

Step 2: We do a fast review of your planned discharge date, checking to see if it
was medically appropriate.
•

During this review, we take a look at all of the information about your hospital stay. We
check to see if your planned discharge date was medically appropriate. We see if the
decision about when you should leave the hospital was fair and followed all the rules.

Step 3: We give you our decision within 72 hours after you ask for a fast review.
•

If we say yes to your appeal, it means we have agreed with you that you still need to be
in the hospital after the discharge date. We will keep providing your covered inpatient
hospital services for as long as they are medically necessary. It also means that we have
agreed to reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. (You must pay your share of the costs and
there may be coverage limitations that apply.)

•

If we say no to your appeal, we are saying that your planned discharge date was
medically appropriate. Our coverage for your inpatient hospital services ends as of the
day we said coverage would end.
o If you stayed in the hospital after your planned discharge date, then you may
have to pay the full cost of hospital care you received after the planned discharge
date.

Step 4: If we say no to your appeal, your case will automatically be sent on to the
next level of the appeals process.
Step-by-Step: Level 2 Alternate appeal Process
Legal Term
The formal name for the independent review organization is the Independent Review Entity.
It is sometimes called the IRE.

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The independent review organization is an independent organization hired by Medicare. It
is not connected with our plan and is not a government agency. This organization decides
whether the decision we made is correct or if it should be changed. Medicare oversees its work.
Step 1: We will automatically forward your case to the independent review
organization.
•

We are required to send the information for your Level 2 appeal to the independent
review organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we are not meeting this deadline or other deadlines, you can
make a complaint. Section 10 of this chapter tells how to make a complaint.)

Step 2: The independent review organization does a fast review of your appeal.
The reviewers give you an answer within 72 hours.
•

Reviewers at the independent review organization will take a careful look at all of the
information related to your appeal of your hospital discharge.

•

If this organization says yes to your appeal, then we must pay you back for our share of
the costs of hospital care you received since the date of your planned discharge. We must
also continue the plan’s coverage of your inpatient hospital services for as long as it is
medically necessary. You must continue to pay your share of the costs. If there are
coverage limitations, these could limit how much we would reimburse or how long we
would continue to cover your services.

•

If this organization says no to your appeal, it means they agree that your planned
hospital discharge date was medically appropriate.
o The written notice you get from the independent review organization will tell how
to start a Level 3 appeal with the review process, which is handled by an
Administrative Law Judge or attorney adjudicator.

Step 3: If the independent review organization turns down your appeal, 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 reviewers say no to your Level 2 appeal, you decide whether to
accept their decision or go on to Level 3 appeal.

•

Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

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SECTION 8

How to ask us to keep covering certain medical
services if you think your coverage is ending too
soon

Section 8.1

This section is only about three services:
Home health care, skilled nursing facility care, and
Comprehensive Outpatient Rehabilitation Facility (CORF)
services

180

When you are getting home health services, skilled nursing care, or rehabilitation care
(Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your
covered services for that type of care for as long as the care is needed to diagnose and treat your
illness or injury.
When we decide it is time to stop covering any of the three types of care for you, we are required
to tell you in advance. When your coverage for that care ends, we will stop paying our share of
the cost for your care.
If you think we are ending the coverage of your care too soon, you can appeal our decision.
This section tells you how to ask for an appeal.
Section 8.2

We will tell you in advance when your coverage will be ending
Legal Term

Notice of Medicare Non-Coverage. It tells you how you can request a fast-track appeal.
Requesting a fast-track appeal is a formal, legal way to request a change to our coverage
decision about when to stop your care.
1. You receive a notice in writing at least two days before our plan is going to stop
covering your care. The notice tells you:
•

The date when we will stop covering the care for you.

•

How to request a fast track appeal to request us to keep covering your care for a
longer period of time.

2. You, or someone who is acting on your behalf, will be asked to sign the written
notice to show that you received it. Signing the notice shows only that you have

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received the information about when your coverage will stop. Signing it does not mean
you agree with the plan’s decision to stop care.
Section 8.3

Step-by-step: How to make a Level 1 appeal to have our plan
cover your care for a longer time

If you want to ask us to cover your care for a longer period of time, you will need to use the
appeals process to make this request. Before you start, understand what you need to do and
what the deadlines are.
•

Follow the process.

•

Meet the deadlines.

•

During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It
decides if the end date for your care is medically appropriate.
The Quality Improvement Organization is a group of doctors and other health care experts
paid by the Federal government to check on and help improve the quality of care for people with
Medicare. This includes reviewing plan decisions about when it’s time to stop covering certain
kinds of medical care. These experts are not part of our plan.
Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization
and ask for a fast-track appeal. You must act quickly.
How can you contact this organization?
•

The written notice you received (Notice of Medicare Non-Coverage) tells you how to
reach this organization. Or find the name, address, and phone number of the Quality
Improvement Organization for your state in Chapter 2.

Act quickly:
•

You must contact the Quality Improvement Organization to start your appeal by noon of
the day before the effective date on the Notice of Medicare Non-Coverage.

•

If you miss the deadline for contacting the Quality Improvement Organization, and you
still wish to file an appeal, you must make an appeal directly to us instead. For details
about this other way to make your appeal, see Section 8.5.

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Step 2: The Quality Improvement Organization conducts an independent review
of your case.
Legal Term
Detailed Explanation of Non-Coverage. Notice that provides details on reasons for ending
coverage.
What happens during this review?
•

Health professionals at the Quality Improvement Organization (the reviewers) will ask
you, or your representative, why you believe coverage for the services should continue.
You don’t have to prepare anything in writing, but you may do so if you wish.

•

The review organization will also look at your medical information, talk with your
doctor, and review information that our plan has given to them.

•

By the end of the day the reviewers tell us of your appeal, you will get the Detailed
Explanation of Non-Coverage from us that explains in detail our reasons for ending our
coverage for your services.

Step 3: Within one full day after they have all the information they need, the
reviewers will tell you their decision.
What happens if the reviewers say yes?
•

If the reviewers say yes to your appeal, then we must keep providing your covered
services for as long as it is medically necessary.

•

You will have to keep paying your share of the costs (such as deductibles or copayments,
if these apply). There may be limitations on your covered services.

What happens if the reviewers say no?
•

If the reviewers say no, then your coverage will end on the date we have told you.

•

If you decide to keep getting the home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when
your coverage ends, then you will have to pay the full cost of this care yourself.

Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make
another appeal.
•

If reviewers say no to your Level 1 appeal – and you choose to continue getting care after
your coverage for the care has ended – then you can make a Level 2 appeal.

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Step-by-step: How to make a Level 2 appeal to have our plan
cover your care for a longer time

During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at
the decision on your first appeal. If the Quality Improvement Organization turns down your
Level 2 appeal, you may have to pay the full cost for your home health care, or skilled nursing
facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date
when we said your coverage would end.
Step 1: Contact the Quality Improvement Organization again and ask for another
review.
•

You must ask for this review within 60 days after the day when the Quality
Improvement Organization said no to your Level 1 appeal. You can ask for this review
only if you continued getting care after the date that your coverage for the care ended.

Step 2: The Quality Improvement Organization does a second review of your
situation.
•

Reviewers at the Quality Improvement Organization will take another careful look at all
of the information related to your appeal.

Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on
your appeal and tell you their decision.
What happens if the review organization says yes?
•

We must reimburse you for our share of the costs of care you have received since the
date when we said your coverage would end. We must continue providing coverage for
the care for as long as it is medically necessary.

•

You must continue to pay your share of the costs and there may be coverage limitations
that apply.

What happens if the review organization says no?
•

It means they agree with the decision made to your Level 1 appeal.

•

The notice you get will tell you in writing what you can do if you wish to continue with
the review process. It will give you the details about how to go on to the next level of
appeal, which is handled by an Administrative Law Judge or attorney adjudicator.

Step 4: If the answer is no, you will need to decide whether you want to take your
appeal further.
•

There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the
written notice you get after your Level 2 appeal decision.

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The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator.
Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

Section 8.5

What if you miss the deadline for making your Level 1 appeal?

You can appeal to us instead
As explained above, you must act quickly to contact the Quality Improvement Organization to
start your first appeal (within a day or two, at the most). If you miss the deadline for contacting
this organization, there is another way to make your appeal. If you use this other way of making
your appeal, the first two levels of appeal are different.
Step-by-Step: How to make a Level 1 Alternate appeal
Legal Term
A fast review (or fast appeal) is also called an expedited appeal.
Step 1: Contact us and ask for a fast review.
•

Ask for a fast review. This means you are asking us to give you an answer using the fast
deadlines rather than the standard deadlines. Chapter 2 has contact information.

Step 2: We do a fast review of the decision we made about when to end coverage
for your services.
•

During this review, we take another look at all of the information about your case. We
check to see if we were following all the rules when we set the date for ending the plan’s
coverage for services you were receiving.

Step 3: We give you our decision within 72 hours after you ask for a fast review.
•

If we say yes to your appeal, it means we have agreed with you that you need services
longer, and will keep providing your covered services for as long as it is medically
necessary. It also means that we have agreed to reimburse you for our share of the costs
of care you have received since the date when we said your coverage would end. (You
must pay your share of the costs and there may be coverage limitations that apply.)

•

If we say no to your appeal, then your coverage will end on the date we told you and we
will not pay any share of the costs after this date.

•

If you continued to get home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when
we said your coverage would end, then you will have to pay the full cost of this care.

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Step 4: If we say no to your fast appeal, your case will automatically go on to the
next level of the appeals process.
Legal Term
The formal name for the independent review organization is the Independent Review Entity.
It is sometimes called the IRE.
Step-by-Step: Level 2 Alternate appeal Process
During the Level 2 appeal, the independent review organization reviews the decision we made
to your fast appeal. This organization decides whether the decision should be changed. The
independent review organization is an independent organization that is hired by Medicare.
This organization is not connected with our plan and it is not a government agency. This
organization is a company chosen by Medicare to handle the job of being the independent review
organization. Medicare oversees its work.
Step 1: We automatically forward your case to the independent review
organization.
•

Step 2: The independent review organization does a fast review of your appeal.
The reviewers give you an answer within 72 hours.
•

Reviewers at the independent review organization will take a careful look at all of the
information related to your appeal.

•

If this organization says yes to your appeal, then we must pay you back for our share of
the costs of care you have received since the date when we said your coverage would
end. We must also continue to cover the care for as long as it is medically necessary. You
must continue to pay your share of the costs. If there are coverage limitations, these could
limit how much we would reimburse or how long we would continue to cover services.

•

If this organization says no to your appeal, it means they agree with the decision our
plan made to your first appeal and will not change it.
o The notice you get from the independent review organization will tell you in
writing what you can do if you wish to go on to a Level 3 appeal.

Step 3: If the independent review organization says no to your appeal, you
choose whether you want to take your appeal further.
•

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A Level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator.
Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 9

Taking your appeal to Level 3 and beyond

Section 9.1

Appeal Levels 3, 4 and 5 for Medical Service Requests

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 dollar value of the item or medical service you have appealed meets certain minimum
levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the
minimum level, you cannot appeal any further. The written response you receive to your Level 2
appeal will explain how to make 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
•

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 Administrative Law Judge or attorney adjudicator says yes to your appeal,
the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we
have the right to appeal a Level 3 decision that is favorable to you. If we decide to appeal,
it will go to a Level 4 appeal.
o If we decide not to appeal, we must authorize or provide you with the service
within 60 calendar days after receiving the Administrative Law Judge’s or
attorney adjudicator’s decision.
o If we decide to appeal the decision, we will send you a copy of the Level 4 appeal
request with any accompanying documents. We may wait for the Level 4 appeal
decision before authorizing or providing the service in dispute.

•

If the Administrative Law Judge or attorney adjudicator says no to your appeal, the
appeals process may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you can continue to the next level of the
review process. The notice you get will tell you what to do for a Level 4 appeal.

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•

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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, or if the Council denies our request to review a favorable Level
3 appeal decision, the appeals process may or may not be over. Unlike a decision at
Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We will
decide whether to appeal this decision to Level 5.
o If we decide not to appeal the decision, we must authorize or provide you with the
service within 60 calendar days after receiving the Council’s decision.
o If we decide to appeal the decision, we will let you know in writing.

•

If the answer is no or if the Council denies the review request, the appeals process
may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you may be able to continue to the next
level of the review process. If the Council says no to your appeal, the notice you
get will tell you whether the rules allow you to go on to a Level 5 appeal and how
to continue with a Level 5 appeal.

Level 5 appeal
•

A judge at the Federal District Court will review your appeal.

A judge will review all of the information and decide yes or no to your request. This is a
final answer. There are no more appeal levels after the Federal District Court.

Section 9.2

Appeal Levels 3, 4 and 5 for Part D Drug Requests

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
•

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. We must authorize or provide the
drug coverage that was approved by the Administrative Law Judge or attorney

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

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. 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.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you may 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 will tell you whether the rules allow you
to go on to a Level 5 appeal. It 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.

A judge will review all of the information and decide yes or no to your request. This is a
final answer. There are no more appeal levels after the Federal District Court.

MAKING COMPLAINTS
SECTION 10

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

Section 10.1

What kinds of problems are handled by the complaint
process?

The complaint process is only used for certain types of problems. This includes problems related
to quality of care, waiting times, and the customer service. Here are examples of the kinds of
problems handled by the complaint process.

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Complaint

Example

Quality of your medical
care

•

Are you unhappy with the quality of the care you have
received (including care in the hospital)?

Respecting your privacy

•

Did someone not respect your right to privacy or share
confidential information?

Disrespect, poor customer
service, or other negative
behaviors

•
•
•

Has someone been rude or disrespectful to you?
Are you unhappy with our Member Services?
Do you feel you are being encouraged to leave the plan?

Waiting times

•

Are you having trouble getting an appointment, or waiting
too long to get it?
Have you been kept waiting too long by doctors,
pharmacists, or other health professionals? Or by our
Member Services or other staff at the plan?
o Examples include waiting too long on the phone, in
the waiting or exam room, or getting a prescription.

•

Cleanliness

•

Are you unhappy with the cleanliness or condition of a
clinic, hospital, or doctor’s office?

Information you get from
us

•
•

Did we fail to give you a required notice?
Is our written information hard to understand?

Timeliness
(These types of complaints
are all related to the timeliness of our actions related
to coverage decisions and
appeals)

If you have asked for a coverage decision or made an appeal,
and you think that we are not responding quickly enough, you
can make a complaint about our slowness. Here are examples:
•
•
•
•

You asked us for a fast coverage decision or a fast appeal,
and we have said no; you can make a complaint.
You believe we are not meeting the deadlines for coverage
decisions or appeals; you can make a complaint.
You believe we are not meeting deadlines for covering or
reimbursing you for certain medical services or drugs that
were approved; you can make a complaint.
You believe we failed to meet required deadlines for
forwarding your case to the independent review
organization; you can make a complaint.

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How to make a complaint
Legal Terms

•

A Complaint is also called a grievance.

•

Making a complaint is also called filing a grievance.

•

Using the process for complaints is also called using the process for filing a grievance.

•

A fast complaint is also called an expedited grievance.

Section 10.3

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.

•

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.]

•

The deadline for making a complaint is 60 calendar days from the time you had the
problem you want to complain about.

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.

•

Most complaints are answered within 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 days total) to answer your complaint. If we decide to
take extra days, we will tell you in writing.

•

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.

•

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 include our reasons in our response to you.

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

When your complaint is about quality of care, you also have two extra options:
•

You can make your complaint directly to the Quality Improvement Organization.
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. Chapter 2 has contact information.
Or

•

You can make your complaint to both the Quality Improvement Organization and
us at the same time.

Section 10.5

You can also tell Medicare about your complaint

You can submit a complaint about [insert 2024 plan name] directly to Medicare. To submit a
complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. You may
also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

CHAPTER 10:

Ending your membership in the plan

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193

Introduction to ending your membership in our plan

Ending your membership in [insert 2024 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. Sections 2
and 3 provide information on ending your membership voluntarily.

•

There are also limited situations where 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, our plan must continue to provide your medical care and prescription
drugs and you will continue to pay your cost share until your membership ends.

SECTION 2

When can you end your membership in our plan?

Section 2.1

You can end your membership during the Annual Enrollment
Period

You can end your membership in our plan during the Annual Enrollment Period (also known
as the Annual Open Enrollment Period). During this time, review your health and drug
coverage and decide about coverage for the upcoming year.
•

The Annual Enrollment Period is from October 15 to December 7.

•

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:
o Another Medicare health plan, with or without prescription drug coverage.
o Original Medicare with a separate Medicare prescription drug plan.

o Original Medicare without a separate Medicare prescription drug plan.


If you choose this option, Medicare may enroll you in a drug plan, unless
you have opted out of automatic enrollment.

Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage for 63 or more days in a row, you may have to pay
a Part D late enrollment penalty if you join a Medicare drug plan later.
•

Your membership will end in our plan when your new plan’s coverage begins on
January 1.

[I-SNPs serving individuals who meet the definition of institutionalized, may rename Section 2.1:
You can end your membership at any time and may replace the language in Section 2.1 with the
following: You can end your membership in [insert 2024 plan name] at any time.

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•

Because you live in a nursing home, you can end your membership in [insert 2024 plan
name] at any time.

•

If you decide to change to a new plan, you can choose any of the following types of
plans:
o Another Medicare health plan with or without prescription drug coverage.
o Original Medicare with a separate Medicare prescription drug plan.

o Original Medicare without a separate Medicare prescription drug plan.

o If you choose this option, Medicare may enroll you in a drug plan, unless you
have opted out of automatic enrollment.
Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage for 63 days or more in a row, you may have to pay
a Part D late enrollment penalty if you join a Medicare drug plan later.
•

Your membership will usually end on the first day of the month after your request to
change your plan is received.]

Section 2.2

You can end your membership during the Medicare Advantage
Open Enrollment Period

[I-SNPs serving individuals who meet the definition of institutionalized: may delete Section 2.2]
You have the opportunity to make one change to your health coverage during the Medicare
Advantage Open Enrollment Period.
•

The annual Medicare Advantage Open Enrollment Period is from January 1 to March
31.

•

During the annual Medicare Advantage Open Enrollment Period you can:
o Switch to another Medicare Advantage Plan with or without prescription drug
coverage.
o Disenroll from our plan and obtain coverage through Original Medicare. If you
choose to switch to Original Medicare during this period, you can also join a
separate Medicare prescription drug plan at that time.

•

Your membership will end on the first day of the month after you enroll in a different
Medicare Advantage plan or we get your request to switch to Original Medicare. If you
also choose to enroll in a Medicare prescription drug plan, your membership in the drug
plan will begin the first day of the month after the drug plan gets your enrollment request.

Section 2.3

In certain situations, you can end your membership during a
Special Enrollment Period

[I-SNPs serving individuals who meet the definition of institutionalized, may delete Section 2.3]

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In certain situations, members of [insert 2024 plan name] may be eligible to end their
membership at other times of the year. This is known as a Special Enrollment Period.
You may be eligible to end your membership during a Special Enrollment Period if any of
the following situations apply to you. These are just examples, for the full list you can contact
the plan, call Medicare, or visit the Medicare website (www.medicare.gov):
•

Usually, when you have moved.

•

[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).]

•

[Note: If you’re in a drug management program, you may not be able to change plans.
Chapter 5, Section 10 tells you more about drug management programs.]

The enrollment time periods vary depending on your situation.
To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800MEDICARE (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. You can choose:
•

Another Medicare health plan with or without prescription drug coverage.

•

Original Medicare with a separate Medicare prescription drug plan.

•

– or – Original Medicare without a separate Medicare prescription drug plan.
Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage for 63 days or more in a row, you may have to pay
a Part D late enrollment penalty if you join a Medicare drug plan later.

Your membership will usually end on the first day of the month after your request to change
your plan is received.
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.
Section 2.4

Where can you get more information about when you can end
your membership?

[I-SNPs serving individuals who meet the definition of institutionalized, may renumber Section
2.4 as Section 2.2.]

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If you have any questions about ending your membership you can:
•

Call Member Services.

•

You can find the information in the Medicare & You 2024 handbook.

•

Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week (TTY 1-877-486-2048).

SECTION 3

How do you end your membership in our plan?

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
health plan.

•

Enroll in the new Medicare health plan.

•

You will automatically be disenrolled from [insert
2024 plan name] when your new plan’s coverage
begins.

Original Medicare
with a separate
Medicare prescription
drug plan.

•

Enroll in the new Medicare prescription drug plan.

•

You will automatically be disenrolled from [insert
2024 plan name] when your new plan’s coverage
begins.

Original Medicare
without a separate
Medicare prescription
drug plan.

SECTION 4

•

Send us a written request to disenroll [insert if
organization has complied with CMS guidelines for
online disenrollment: or visit our website to disenroll
online]. Contact Member Services if you need more
information on how to do this.

•

You can also contact Medicare, at 1-800MEDICARE (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.

•

You will be disenrolled from [insert 2024 plan name]
when your coverage in Original Medicare begins.

Until your membership ends, you must keep getting
your medical services and drugs through our plan

Until your membership ends, and your new Medicare coverage begins, you must continue to get
your medical care and prescription drugs through our plan.

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•

Continue to use our network providers to receive medical care.

•

Continue to use our network pharmacies [insert if appropriate or mail order] to get
your prescriptions filled.

•

If you are hospitalized on the day that your membership ends, your hospital stay
will be covered by our plan until you are discharged (even if you are discharged after
your new health coverage begins).

SECTION 5

[Insert 2024 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 2024 plan name] must end your membership in the plan if any of the following
happen:
•

If you no longer have Medicare Part A and Part B.

•

If you move out of our service area.

•

If you are away from our service area for more than six months. [Plans with
visitor/traveler benefits should revise this bullet to indicate when members must be
disenrolled from the plan.]
o If you move or take a long trip, call Member Services to find out if the place you
are moving or traveling to is in our plan’s area.
o [Plans with grandfathered members who were outside of area prior to January
1999, insert: If you have been a member of our plan continuously prior to 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. However,
if you move and your move is to another location that is outside of our service
area, you will be disenrolled from our plan.]

•

[I-SNPs and C-SNPs insert: You do not meet the plan’s special eligibility requirements.
o [I-SNPs and C-SNPs: Insert rules for members who no longer meet special
eligibility requirements.]

•

If you become incarcerated (go to prison).

•

If you are no longer a United States citizen or lawfully present in the United States.

•

If you lie 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.)

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•

[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 medical 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 medical care. (We cannot make you leave our plan for this reason
unless we get permission from Medicare first.)
o 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].
o 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 call
Member Services.
Section 5.2

We cannot ask you to leave our plan for any health-related
reason

[Chronic care SNPs should use the following title for this section instead: We cannot ask you to
leave our plan for any health-related reason, unless you no longer have a medical condition
required for enrollment in [insert 2024 plan name].]
[Insert 2024 plan name] is not allowed to ask you to leave our plan for any health-related reason.
[Chronic care SNPs replace sentence above with: In most cases, [insert 2024 plan name] cannot
ask you to leave our plan for any health-related reason. The only time we are allowed to do this
is if you no longer have [insert as applicable: the medical condition OR both of the medical
conditions OR all of the medical conditions] required for enrollment in [insert 2024 plan name].

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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, call
Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. (TTY 1-877486-2048).
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 can file a grievance or make a complaint about our
decision to end your membership.

CHAPTER 11:

Legal notices

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SECTION 1

201

Notice about governing law

The principal law that applies to this Evidence of Coverage 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. This may affect your rights and
responsibilities even if the laws are not included or explained in this document.

SECTION 2

Notice about nondiscrimination

[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, sexual orientation, mental or physical disability, health status, claims experience,
medical history, genetic information, evidence of insurability, or geographic location within the
service area. All organizations that provide Medicare Advantage 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.
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. You can also review information
from the Department of Health and Human Services’ Office for Civil Rights
athttps://www.hhs.gov/ocr/index.html.
If you have a disability and need help with access to care, please call us at Member Services. If
you have a complaint, such as a problem with wheelchair access, Member Services can help.

SECTION 3

Notice about Medicare Secondary Payer subrogation
rights

We have the right and responsibility to collect for covered Medicare services for which Medicare
is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and
423.462, [insert 2024 plan name], as a Medicare Advantage Organization, 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 or 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.
Plans may also include Medicaid-related legal notices.]

CHAPTER 12:

Definitions of important words

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[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.]
[If you use any of the following terms in your EOC, you must add a definition of the term to the
first section where you use it and here in Chapter 12 with a reference from the section where you
use it: IPA, network, PHO, plan medical group, Point of Service.]
[Plans with a POS option: Provide definitions of: allowed amount, balance billing, coinsurance
and maximum charge, and prescription drug benefit manager.]
Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates
exclusively for the purpose of furnishing outpatient surgical services to patients not requiring
hospitalization and whose expected stay in the center does not exceed 24 hours.
Annual Enrollment Period – The time period of October 15 until December 7 of each year
when members can change their health or drug plans or switch to Original Medicare.
Appeal – An appeal is something you do if you disagree with our decision to deny a request for
coverage of health care services or prescription drugs or payment for services or drugs you
already received. You may also make an appeal if you disagree with our decision to stop services
that you are receiving.
Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the
plan’s allowed cost-sharing amount. As a member of [insert 2024 plan name], you only have to
pay our plan’s cost-sharing amounts when you get services covered by our plan. We do not allow
providers to balance bill or otherwise charge you more than the amount of cost sharing your
plan says you must pay.
Benefit Period – [Modify definition as needed if plan uses benefit periods for SNF stays but not
for inpatient hospital stays.] The way that [insert if applicable: both our plan and] Original
Medicare measures your use of hospital and skilled nursing facility (SNF) services. [Plans that
offer a more generous benefit period, revise the following sentences to reflect the plan’s benefit
period.] A benefit period begins the day you go into a hospital or skilled nursing facility. The
benefit period ends when you have not received any inpatient hospital care (or skilled care in a
SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit
period has ended, a new benefit period begins. [Insert if applicable: You must pay the inpatient
hospital deductible for each benefit period.] There is no limit to the number of benefit periods.
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.

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Catastrophic Coverage Stage – The stage in the Part D Drug Benefit that begins when you (or
other qualified parties on your behalf) have spent $[insert 2024 out-of-pocket threshold] for Part
D covered drugs during the covered year. During this payment stage, the plan pays the full cost
for your covered Part D drugs. You pay nothing.
Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers
Medicare.
Chronic-Care Special Needs Plan – C-SNPs are SNPs that restrict enrollment to special needs
individuals with specific severe or disabling chronic conditions, defined in 42 CFR 422.2. A CSNP must have specific attributes that go beyond the provision of basic Medicare Parts A and B
services and care coordination that is required of all Medicare Advantage Coordinated Care
Plans, in order to receive the special designation and marketing and enrollment accommodations
provided to C-SNPs.
Coinsurance – An amount you may be required to pay, expressed as a percentage (for example
20%) as your share of the cost for services or prescription drugs [insert if applicable: after you
pay any deductibles].
Complaint - The formal name for making a complaint is filing a grievance. The complaint
process is used only for certain types of problems. This includes problems related to quality of
care, waiting times, and the customer service you receive. It also includes complaints if your plan
does not follow the time periods in the appeal process.
Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides
rehabilitation services after an illness or injury, including physical therapy, social or
psychological services, respiratory therapy, occupational therapy and speech-language pathology
services, and home environment evaluation services.
Copayment (or copay) – An amount you may be required to pay as your share of the cost for a
medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A
copayment is a set amount (for example $10), rather than a percentage.
Cost Sharing – Cost sharing refers to amounts that a member has to pay when services or 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 services or drugs are covered; (2) any fixed
copayment amount that a plan requires when a specific service or drug is received; or (3) any
coinsurance amount, a percentage of the total amount paid for a service or drug, that a plan
requires when a specific service or drug is received.
[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

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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 document.
Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.
Covered Services – The term we use to mean all of the health care services and supplies that are
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.
Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or other
facility setting when you do not need skilled medical care or skilled nursing care. Custodial care,
provided by people who do not have professional skills or training, includes help with activities
of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around,
and using the bathroom. It may also include the kind of health-related care that most people do
themselves, like using eye drops. Medicare doesn’t pay for custodial care.
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.
Deductible – The amount you must pay for health care or prescriptions before our plan pays.
Disenroll or Disenrollment – The process of ending your membership in our plan.
Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of
filling a prescription, such as the pharmacist’s time to prepare and package the prescription.
Dual Eligible Special Needs Plans (D-SNP) – D-SNPs enroll individuals who are entitled to
both Medicare (title XVIII of the Social Security Act) and medical assistance from a state plan
under Medicaid (title XIX). States cover some Medicare costs, depending on the state and the
individual’s eligibility.
Durable Medical Equipment (DME) – Certain medical equipment that is ordered by your
doctor for medical reasons. Examples include: walkers, wheelchairs, crutches, powered mattress
systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment,
nebulizers, or hospital beds ordered by a provider for use in the home.

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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 (and, if you are a pregnant woman, loss of an
unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a
bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical
condition that is quickly getting worse.
Emergency Care – Covered services that are: 1) provided by a provider qualified to furnish
emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical
condition.
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 decision that, if approved, allows you to get a drug that is not on
our 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 our plan requires you to try another
drug before receiving the drug you are requesting, or if our plan limits the quantity or dosage of
the drug you are requesting (a formulary exception).
“Extra Help” – A Medicare or a State 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 our plan, providers, or pharmacies, including a
complaint concerning the quality of your care. This does not involve coverage or payment
disputes.
Home Health Aide – A person who provides services that do not need the skills of a licensed
nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or
carrying out the prescribed exercises).
Hospice - A benefit that provides special treatment for a member who has been medically
certified as terminally ill, meaning having a life expectancy of 6 months or less. We, your plan,
must provide you with a list of hospices in your geographic area. If you elect hospice and
continue to pay premiums you are still a member of our plan. You can still obtain all medically
necessary services as well as the supplemental benefits we offer.
Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital
for skilled medical services. Even if you stay in the hospital overnight, you might still be
considered an outpatient.

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Income Related Monthly Adjustment Amount (IRMAA) – If your modified adjusted gross
income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay
the standard premium amount and an Income Related Monthly Adjustment Amount, also known
as IRMAA. IRMAA is an extra charge added to your premium. 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 2024 initial coverage limit] OR
[insert 2024 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. 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.
Institutional Special Needs Plan (SNP) – A plan that enrolls eligible individuals who
continuously reside or are expected to continuously reside for 90 days or longer in a long-term
care (LTC) facility. These facilities may include a skilled nursing facility (SNF), nursing facility
(NF), (SNF/NF), an Intermediate Care Facility for Individuals with Intellectual Disabilities
(ICF/IID), an inpatient psychiatric facility, and/or facilities approved by CMS that furnishes
similar long-term, healthcare services that are covered under Medicare Part A, Medicare Part B,
or Medicaid; and whose residents have similar needs and healthcare status to the other named
facility types. An institutional Special Needs Plan must have a contractual arrangement with (or
own and operate) the specific LTC facility(ies).
Institutional Equivalent Special Needs Plan (SNP) – A plan that enrolls eligible individuals
living in the community but requiring an institutional level of care based on the State assessment.
The assessment must be performed using the same respective State level of care assessment tool
and administered by an entity other than the organization offering the plan. This type of Special
Needs Plan may restrict enrollment to individuals that reside in a contracted assisted living
facility (ALF) if necessary to ensure uniform delivery of specialized care.
List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by
the plan.
Low Income Subsidy (LIS) – See “Extra Help.”
[POS plans may revise this definition as needed to describe the plan’s MOOP(s)] Maximum
Out-of-Pocket Amount – The most that you pay out-of-pocket during the calendar year for innetwork covered [insert if applicable: Part A and Part B] services. [Plans without a premium
revise the following sentence as needed] Amounts you pay for your plan premiums, Medicare
Part A and Part B premiums, and prescription drugs do not count toward the maximum out-ofpocket amount. [Plans with service category MOOPs insert: In addition to the maximum out-of-

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pocket amount for in-network covered [insert if applicable: Part A and Part B] medical services,
we also have a maximum out-of-pocket amount for certain types of services.]
Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical
costs for some people with low incomes and limited resources. State Medicaid programs vary,
but most health care costs are covered if you qualify for both Medicare and Medicaid.
Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug
Administration or supported by certain reference books.
Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of medical practice.
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).
Medicare Advantage Open Enrollment Period – The time period from January 1 until March
31 when members in a Medicare Advantage plan can cancel their plan enrollment and switch to
another Medicare Advantage plan, or obtain coverage through Original Medicare. If you choose
to switch to Original Medicare during this period, you can also join a separate Medicare
prescription drug plan at that time. The Medicare Advantage Open Enrollment Period is also
available for a 3-month period after an individual is first eligible for Medicare.
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 i) HMO, ii) PPO, a iii) Private Fee-forService (PFFS) plan, or a iv) Medicare Medical Savings Account (MSA) plan. Besides choosing
from these types of plans, a Medicare Advantage HMO or PPO plan can also be a Special Needs
Plan (SNP). 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.
[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.
Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare
health plans must cover all of the services that are covered by Medicare Part A and B. The term
Medicare-Covered Services does not include the extra benefits, such as vision, dental or hearing,
that a Medicare Advantage plan may offer.

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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, Special Needs
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.
Network Pharmacy – A pharmacy that contracts with our plan where members of our plan can
get their prescription drug benefits. In most cases, your prescriptions are covered only if they are
filled at one of our network pharmacies.
Network Provider – Provider is the general term for doctors, other health care professionals,
hospitals, and other health care facilities that are licensed or certified by Medicare and by the
State to provide health care services. Network providers have an agreement with our plan to
accept our payment as payment in full, and in some cases to coordinate as well as provide
covered services to members of our plan. Network providers are also called plan providers.
[Include if applicable: Optional Supplemental Benefits – Non-Medicare-covered benefits that
can be purchased for an additional premium and are not included in your package of benefits.
You must voluntarily elect Optional Supplemental Benefits in order to get them.]
Organization Determination – A decision our plan makes about whether items or services are
covered or how much you have to pay for covered items or services. Organization
determinations are called coverage decisions in this document.
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.

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Chapter 12 Definitions of important words

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Out-of-Network Pharmacy – A pharmacy that does not have a contract with our plan to
coordinate or provide covered drugs to members of our plan. Most drugs you get from out-ofnetwork pharmacies are not covered by our plan unless certain conditions apply.
Out-of-Network Provider or Out-of-Network Facility – A provider or facility that does not
have a contract with our plan to coordinate or provide covered services to members of our plan.
Out-of-network providers are providers that are not employed, owned, or operated by our plan.
Out-of-Pocket Costs – See the definition for cost sharing above. A member’s cost-sharing
requirement to pay for a portion of services or 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
services and supports (LTSS) for frail people to help people stay independent and living in their
community (instead of moving to a nursing home) as long as possible. People enrolled in PACE
plans receive both their Medicare and Medicaid benefits through the plan.]
Part C – see Medicare Advantage (MA) Plan.
Part D – The voluntary Medicare Prescription Drug Benefit Program.
Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D
drugs. Certain categories of drugs have been excluded as covered Part D drugs by Congress.
Certain categories of Part D drugs must be covered by every plan.
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 after you are first eligible to join a Part D plan.
[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.]
Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a
Medicare Advantage Plan that has a network of contracted providers that have agreed to treat
plan members for a specified payment amount. A PPO plan must cover all plan benefits whether
they are received from network or out-of-network providers. Member cost sharing will generally
be higher when plan benefits are received from out-of-network providers. PPO plans have an
annual limit on your out-of-pocket costs for services received from network (preferred) providers
and a higher limit on your total combined out-of-pocket costs for services from both network
(preferred) and out-of-network (non-preferred) providers.

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Chapter 12 Definitions of important words

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Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
[Plans that do not use PCPs, omit] Primary Care [insert as appropriate: Physician OR
Provider] (PCP) – The doctor or other provider you see first for most health problems. In many
Medicare health plans, you must see your primary care provider before you see any other health
care provider.
Prior Authorization – Approval in advance to get services or certain drugs. [Plans may delete
applicable sentences if it does not require prior authorization for any medical services and/or
any drugs.] Covered services that need prior authorization are marked in the Benefits Chart in
Chapter 4. Covered drugs that need prior authorization are marked in the formulary.
Prosthetics and Orthotics – Medical devices including, but are not limited to: arm, back and
neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part
or function, including ostomy supplies and enteral and parenteral nutrition therapy.
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.
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.
Real Time Benefit Tool – A portal or computer application in which enrollees can look up
complete, accurate, timely, clinically appropriate, enrollee-specific formulary and benefit
information. This includes cost sharing amounts, alternative formulary medications that may be
used for the same health condition as a given drug, and coverage restrictions (Prior
Authorization, Step Therapy, Quantity Limits) that apply to alternative medications.
Rehabilitation Services – These services include physical therapy, speech and language
therapy, and occupational therapy.
Service Area – A geographic area where you must live to join a particular health plan. For plans
that limit which doctors and hospitals you may use, it’s also generally the area where you can get
routine (non-emergency) services. The plan must disenroll you if you permanently move out of
the plan’s service area.
Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided
on a continuous, daily basis, in a skilled nursing facility. Examples of care include physical
therapy or intravenous injections that can only be given by a registered nurse or doctor.
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.

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Chapter 12 Definitions of important words

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Special Needs Plan – A special type of Medicare Advantage Plan that provides more focused
health care for specific groups of people, such as those who have both Medicare and Medicaid,
who reside in a nursing home, or who have certain chronic medical conditions.
[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.
Urgently Needed Services – Covered services that are not emergency services, provided when
the network providers are temporarily unavailable or inaccessible or when the enrollee is out of
the service area. For example, you need immediate care during the weekend. Services must be
immediately needed and medically necessary.

[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 2024 plan name] Member Services
Method

Member Services – Contact Information

CALL

TTY

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

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.

File Type	application/pdf
File Title	2023 Health Maintenance Organization Medicare Advantage Part-D (HMO MAPD) Evidence of Coverage (EOC) Templates
Subject	2023 Health Maintenance Organization Medicare Advantage Part-D (HMO MAPD) Evidence of Coverage (EOC) Template
Author	Centers for Medicare & Medicaid Services
File Modified	2023-04-08
File Created	2023-04-08