CY2024_9_PDP_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_9_PDP_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 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 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]. (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 Part D sponsor name] [insert DBA
names in parentheses, as applicable, after listing required Part D sponsor names throughout this
document]. (When this Evidence of Coverage says “we,” “us,” or “our,” it means [insert Part D
sponsor name] [insert DBA names in parentheses, as applicable, after listing required Part D
sponsor 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 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.

OMB Approval 0938-1051 (Expires: February 29, 2024)

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

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................................................................. 4
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7

Introduction ........................................................................................................5
What makes you eligible to be a plan member? ................................................6
Important membership materials you will receive.............................................7
Your monthly costs for [insert 2024 plan name] ..............................................8
More information about your monthly premium .............................................12
Keeping your plan membership record up to date ...........................................14
How other insurance works with our plan .......................................................15

CHAPTER 2: Important phone numbers and resources ......................................... 17
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) ..................................................................................18
Medicare (how to get help and information directly from the Federal
Medicare program)...........................................................................................21
State Health Insurance Assistance Program (free help, information,
and answers to your questions about Medicare) ..............................................22
Quality Improvement Organization .................................................................24
Social Security .................................................................................................25
Medicaid ..........................................................................................................26
Information about programs to help people pay for their prescription
drugs .................................................................................................................27
How to contact the Railroad Retirement Board ...............................................29
Do you have group insurance or other health insurance from an
employer? .........................................................................................................30

CHAPTER 3: Using the plan’s coverage for Part D prescription drugs ................. 31
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7

Introduction ......................................................................................................32
Fill your prescription at a network pharmacy [insert if applicable: or
through the plan’s mail-order service] .............................................................32
Your drugs need to be on the plan’s “Drug List” ............................................37
There are restrictions on coverage for some drugs ..........................................39
What if one of your drugs is not covered in the way you’d like it to be
covered? ...........................................................................................................40
What if your coverage changes for one of your drugs? ...................................43
What types of drugs are not covered by the plan? ...........................................46

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

SECTION 8 Filling a prescription ........................................................................................48
SECTION 9 Part D drug coverage in special situations .......................................................48
SECTION 10 Programs on drug safety and managing medications ......................................50
CHAPTER 4: What you pay for your Part D prescription drugs ............................. 53
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5
SECTION 6
SECTION 7
SECTION 8
SECTION 9

Introduction ......................................................................................................54
What you pay for a drug depends on which drug payment stage you
are in when you get the drug ............................................................................57
We send you reports that explain payments for your drugs and which
payment stage you are in..................................................................................57
During the Deductible Stage, you pay the full cost of your [insert drug
tiers if applicable] drugs ..................................................................................59
During the Initial Coverage Stage, the plan pays its share of your drug
costs and you pay your share ...........................................................................59
Costs in the Coverage Gap Stage .....................................................................64
During the Catastrophic Coverage Stage, the plan pays the full cost for
your covered Part D drugs ...............................................................................65
Additional benefits information .......................................................................65
Part D Vaccines. What you pay for depends on how and where you get
them..................................................................................................................65

CHAPTER 5: Asking us to pay our share of the costs for covered drugs ............. 68
SECTION 1
SECTION 2
SECTION 3

Situations in which you should ask us to pay our share of the cost of
your covered drugs ...........................................................................................69
How to ask us to pay you back ........................................................................70
We will consider your request for payment and say yes or no ........................70

CHAPTER 6: Your rights and responsibilities ......................................................... 72
SECTION 1
SECTION 2

Our plan must honor your rights and cultural sensitivities as a member
of the plan ........................................................................................................73
You have some responsibilities as a member of the plan ................................77

CHAPTER 7: What to do if you have a problem or complaint (coverage
decisions, appeals, complaints) .......................................................... 79
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5

Introduction ......................................................................................................80
Where to get more information and personalized assistance ...........................80
To deal with your problem, which process should you use? ...........................81
A guide to the basics of coverage decisions and appeals.................................82
Your Part D prescription drugs: How to ask for a coverage decision or
make an appeal.................................................................................................84

2024 Evidence of Coverage for [insert 2024 plan name]

Table of Contents

SECTION 6
SECTION 7

Taking your appeal to Level 3 and beyond ......................................................93
How to make a complaint about quality of care, waiting times,
customer service, or other concerns .................................................................94

CHAPTER 8: Ending your membership in the plan ................................................. 98
SECTION 1
SECTION 2
SECTION 3
SECTION 4
SECTION 5

Introduction to ending your membership in our plan ......................................99
When can you end your membership in our plan? ..........................................99
How do you end your membership in our plan? ............................................101
Until your membership ends, you must keep getting your drugs
through our plan .............................................................................................102
[Insert 2024 plan name] must end your membership in the plan in
certain situations ............................................................................................103

CHAPTER 9: Legal notices...................................................................................... 105
SECTION 1
SECTION 2
SECTION 3

Notice about governing law ...........................................................................106
Notice about nondiscrimination .....................................................................106
Notice about Medicare Secondary Payer subrogation rights .........................106

CHAPTER 10: Definitions of important words ....................................................... 107

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 Prescription Drug Plan

You are covered by Original Medicare or another health plan for your health care coverage, and
you have chosen to get your Medicare prescription drug coverage through our plan, [insert 2024
plan name].
[Insert 2024 plan name] is a Medicare prescription drug plan (PDP). Like all Medicare plans,
this Medicare prescription drug plan is approved by Medicare and run by a private company.
Section 1.2

What is the Evidence of Coverage document about?

This Evidence of Coverage document tells you how to get your 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 drugs refer to the prescription drug coverage 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 coverage is 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.
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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

SECTION 2

What makes you eligible to be a plan member?

Section 2.1

Your eligibility requirements

You are eligible for membership in our plan as long as:
•

You have Medicare Part A or Medicare Part B (or you have both Part A and Part B)

•

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

•

-- and -- you live in our geographic service area (Section 2.2 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.

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 must continue to reside in the plan service area. The service
area is described [insert as appropriate: below OR in an appendix to this Evidence of Coverage].
[Insert plan service area here or within an appendix. Plans may include references to territories
as appropriate. Examples of the format for describing the service area are provided below:
Our service area includes all 50 states
Our service area includes these states: [insert states]]
[Optional info: multi-state plans may include the following: We offer coverage in [insert as
applicable: several OR all] states [insert if applicable: and territories]. However, there may be
cost or other differences between the plans we offer in each state. If you move out of state [insert
if applicable: or territory] and into a state [insert if applicable: or territory] that is still within our
service area, you must call Member Services in order to update your information. [National
plans delete this paragraph.]
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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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

While you are a member of our plan, you must use your membership card for prescription drugs
you get at network pharmacies. You should also show the provider your Medicaid card, if
applicable. Here’s a sample membership card to show you what yours will look like:
[Insert picture of front and back of member ID card. Mark it as a sample card (for example, by
superimposing the word: sample on the image of the card).]
Please carry your card with you at all times and remember to show your card when you get
covered drugs. If your plan membership card is damaged, lost, or stolen, call Member Services
right away and we will send you a new card.
You may need to use your red, white, and blue Medicare card to get covered medical care and
services under Original Medicare.
Section 3.2

Pharmacy Directory

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 3, 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,
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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

Section 3.3

The plan’s List of Covered Drugs (Formulary)

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

Your costs may include the following:
•
•
•
•

Plan Premium (Section 4.1)
Monthly Medicare Part B Premium (Section 4.2)
Part D Late Enrollment Penalty (Section 4.3)
Income Related Monthly Adjusted Amount (Section 4.4)

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.”

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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 1-800MEDICARE (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.]
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

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

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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.
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

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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
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 4.4

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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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.]
Option 1: Paying by check
[Insert plan specifics regarding premium payment intervals (e.g., monthly, quarterly- please 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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

Option [insert number]: Having your premium 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 plan premium
[Plans that do not disenroll members for non-payment may modify this section as needed.]
Your plan premium is due in our office by the [insert day of the month]. [Plans with no
premium: 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 premium by the [insert day
of the month], we will send you a notice telling you that your plan membership will end if we do
not receive your premium payment within [insert length of plan grace period].
If you are having trouble paying your premium on time, please contact Member Services to see if
we can direct you to programs that will help with your plan premium.
If we end your membership because you did not pay your premiums, you will still 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 premiums
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 7 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 7, Section 7 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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 1 Getting started as a member

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.

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

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

•

Changes in any other medical or drug insurance coverage you have (such as from your
employer, your spouse 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 your designated responsible party (such as a caregiver) changes

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 D coverage determinations,
appeals, and/or complaints, you may combine the appropriate sections below.]
How to contact us when you are asking for a coverage decision or appeal
A coverage decision is a decision we make about your coverage or about the amount we will
pay for your Part D prescription drugs. An appeal is a formal way of asking us to review and
change a coverage decision we have made. For more information on asking for coverage
decisions or appeals about your Part D prescription drugs, see Chapter 7 (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)).

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

Coverage Decisions and Appeals for Part D prescription drugs –
Contact Information

CALL

[Insert phone number]
Calls to this number are [insert if applicable: not] free. [Insert days
and hours of operation] [Note: You may also include reference to 24hour lines here.] [Note: If you have a different number for accepting
expedited coverage 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
coverage determinations, also include that number here.]

FAX

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

WRITE

[Insert address] [Note: If you have a different address for accepting
expedited coverage 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
You can make a complaint about us or one of our network pharmacies, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. For more information on making a complaint, see Chapter 7 (What to do if you have
a problem or complaint (coverage decisions, appeals, complaints)).

Method

Complaints – Contact Information

CALL

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

Complaints – Contact Information

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
grievances, also include that number here.]
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 of a drug you
have received
The coverage determination process includes determining requests to pay for our share of the
costs of a drug that you have received. If you have received a bill or paid for drugs (such as a
pharmacy bill) that you think we should pay for, you may need to ask the plan for
reimbursement or to pay the pharmacy bill, see Chapter 5 (Asking us to pay our share of the
costs for covered drugs).
Please note: If you send us a payment request and we deny any part of your request, you can
appeal our decision. See Chapter 7 (What to do if you have a problem or complaint (coverage
decisions, appeals, complaints)) for more information.

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 Prescription Drug Plans,
including us.
Method

Medicare – Contact Information

CALL

1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.

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 up-to-date
information about Medicare and current Medicare issues. It also has
information about hospitals, nursing homes, physicians, home health
agencies, and dialysis facilities. It includes 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:

WEBSITE
(continued)

•

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),

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

and include a list of names, phone numbers, and addresses for all SHIPs in your service area.
Plans have the option of including a separate exhibit to list information for all states in which
the plan is filed, and should 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.

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

CALL

[Insert phone number(s)]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the SHIP uses a direct TTY number: This number requires
special telephone equipment and is only for people who have
difficulties with hearing or speaking.]

WRITE

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

WEBSITE

[Insert URL]

SECTION 4

Quality Improvement Organization

[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 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] if you have a complaint about the quality
of care you have received. For example, you can contact [insert state-specific QIO name] if
you were given the wrong medication or if you were given medications that interact in a
negative way.

2024 Evidence of Coverage for [insert 2024 plan name]

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

CALL

[Insert phone number(s) and days and hours of operation]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the QIO uses a direct TTY number: This number requires
special telephone equipment and is only for people who have
difficulties with hearing or speaking.]

WRITE

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

WEBSITE

[Insert URL]

SECTION 5

Social Security

Social Security is responsible for determining eligibility and handling enrollment for
Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a
disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare.
If you are already getting Social Security checks, enrollment into Medicare is automatic. If
you are not getting Social Security checks, you have to enroll in Medicare. 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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

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/

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].

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

Method

[Insert state-specific Medicaid agency] [If the agency’s name does not
include the name of the state, add: ([insert state name]’s Medicaid
program)] – Contact Information

CALL

[Insert phone number(s) and days and hours of operation]

TTY

[Insert number, if available. Or delete this row.]
[Insert if the state Medicaid program uses a direct TTY number: This
number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.]

WRITE

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

WEBSITE

[Insert URL]

SECTION 7

Information about programs to help people pay for
their prescription drugs

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, [insert if
applicable: yearly deductible,] and prescription [insert as applicable: copayments OR
coinsurance OR copayments and coinsurance]. This “Extra Help” also counts toward your
out-of-pocket 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.)

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

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 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 Help
section if the EOC is used for plans in the U.S Territories and mainland regions: There are
programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American
Samoa to help people with limited income and resources pay their Medicare costs. Programs
vary in these areas. Call your local Medical Assistance (Medicaid) office to find out more about
their rules (phone numbers are in Section 6 of this chapter). Or call 1-800-MEDICARE (1-800633-4227) 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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

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.
[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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 2 Important phone numbers and resources

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.

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’s coverage for Part D
prescription drugs

2024 Evidence of Coverage for [insert 2024 plan name]

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

SECTION 1

Introduction

This chapter explains rules for using your coverage for Part D drugs.
In addition to your coverage for Part D drugs through our plan, Original Medicare (Medicare
Part A and Part B) also covers some drugs:
•

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

•

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

The two examples of drugs described above are covered by Original Medicare. (To find out more
about this coverage, see your Medicare & You 2024 handbook.) Your Part D prescription drugs
are covered under our plan.
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.)

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

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.
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.)

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

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

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

[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
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. [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 are in need of more medication,
and you can cancel scheduled refills if you have enough of your medication or if your
medication has changed.
If you choose not to use our auto-refill program 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.

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

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

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 5, Section 2 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
applicable: or biological product] and usually cost less. There are generic drug substitutes [Insert

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

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.]
What is not on the “Drug List?”
The plan does not cover all prescription drugs.
•

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

•

In other cases, we have decided not to include a particular drug on 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 7.

Section 3.2

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

[Plans that do not use drug tiers should omit this section.]
Every drug on the plan’s “Drug List” is in one of [insert number of tiers] cost-sharing tiers. In
general, the higher the cost-sharing tier, the higher your cost for the drug:
•

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

To find out which cost-sharing tier your drug is in, look it up in the plan’s “Drug List.”
The amount you pay for drugs in each cost-sharing tier is shown in Chapter 4 (What you pay for
your Part D prescription drugs).
Section 3.3

How can you find out if a specific drug is on the “Drug List?”

You have [insert number] ways to find out:
1. Check the most recent “Drug List” we [insert: sent you in the mail] OR [insert:
provided electronically]. [Insert if applicable: (Please note: The “Drug List” we
provide includes information for the covered drugs that are most commonly used
by our members. However, we cover additional drugs that are not included in the

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

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 way. To find out if any of these restrictions apply to a drug you take
or want to take, check the “Drug List.”
Please note that sometimes a drug may appear more than once in 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
restriction for you, you will need to use the coverage decision process and ask us to make an
exception. We may or may not agree to waive the restriction for you. (See Chapter 7.)
[Plans should include only the forms of utilization management used by the plan.]

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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.

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.

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

•

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.
•
•
•

•

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:

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

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.
If you and your provider want to ask for an exception, Chapter 7, Section 5.4 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:

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

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. 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.
You can ask for an exception
You and your provider can ask the plan to make an exception in the cost-sharing tier for the drug
so that you pay less for it. If your provider says that you have medical reasons that justify asking
us for an exception, your provider can help you request an exception to the rule.
If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It
explains the procedures and deadlines that have been set by Medicare to make sure your request
is handled promptly and fairly.
[Insert if 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 of 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].

SECTION 6

What if your coverage changes for one of your
drugs?

Section 6.1

The “Drug List” can change during the year

Most of the changes in drug coverage happen at the beginning of each year (January 1).
However, during the year, the plan 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.

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

•

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)
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 7.]

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

[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 7.]

[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
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.

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

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 7.
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 changes 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.
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 7.)

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

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

•

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 toward qualifying you for the Catastrophic
Coverage Stage. (The Catastrophic Coverage Stage is described in Chapter 4, 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.)]

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

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 5, Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 9

Part D drug coverage in special situations

Section 9.1

What if you’re in a hospital or a skilled nursing facility?

If you are admitted to a hospital or to a skilled nursing facility, Original Medicare (or your
Medicare health plan with Part A and B coverage, if applicable) will generally cover the cost of
your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility,
our 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.

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

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 are taking drugs covered by Original Medicare?

Your enrollment in [insert 2024 plan name] doesn’t affect your coverage for drugs covered
under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will
still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In
addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it,
even if you choose not to enroll in Part A or Part B.
Some drugs may be covered under Medicare Part B in some situations and through [insert 2024
plan name] in other situations. But drugs are never covered by both Part B and our plan at the
same time. In general, your pharmacist or provider will determine whether to bill Medicare Part
B or [insert 2024 plan name] for the drug.
Section 9.4

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

If you currently have a Medigap policy that includes coverage for prescription drugs, you must
contact your Medigap issuer and tell them you have enrolled in our plan. If you decide to keep
your current Medigap policy, your Medigap issuer will remove the prescription drug coverage
portion of your Medigap policy and lower your premium.
Each year your Medigap insurance company should send you a notice that tells if your
prescription drug coverage is creditable, and the choices you have for drug coverage. (If the
coverage from the Medigap policy is creditable, it means that it is expected to pay, on average, at
least as much as Medicare’s standard prescription drug coverage.) The notice will also explain
how much your premium would be lowered if you remove the prescription drug coverage portion
of your Medigap policy. If you didn’t get this notice, or if you can’t find it, contact your
Medigap insurance company and ask for another copy.
Section 9.5

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

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.

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

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.
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 the employer or retiree group’s benefits administrator or the employer or union.
Section 9.6

What if you are 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

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

•

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.
Section 10.2

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 7 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.

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

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
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 4:

What you pay for your Part D
prescription drugs

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

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 LowIncome 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 3, not all
drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and other
drugs are excluded from Medicare coverage by law. [Optional for plans that provide
supplemental coverage: Some excluded drugs may be covered by our plan if you have purchased
supplemental drug coverage.]
To understand the payment information, 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 3,
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 of the drug 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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Chapter 4 What you pay for your Part D prescription drugs

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 3):
•

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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Chapter 4 What you pay for your Part D prescription drugs

•

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

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. [Plans with no premium delete the following sentence] Keep in mind you are always
responsible for the plan’s monthly premium regardless of the drug payment stage. 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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Chapter 4 What you pay for your Part D prescription drugs

•

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 5, 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 a 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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

SECTION 4

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:
•

[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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

•

[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.]

•

[Plans with retail network pharmacies that offer preferred cost sharing, insert: A
network retail pharmacy that offers preferred cost sharing. Costs may be less at
pharmacies that offer 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 3, 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 3
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
different rates. Removed columns do not apply (e.g., preferred cost sharing or mail order). 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].]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

Your share of the cost when you get a one-month supply of a covered Part D
prescription drug:
Standard
retail cost
sharing (innetwork)
(up to a
[insert
number of
days]-day
supply)

Preferred
retail cost
sharing (innetwork)
(up to a
[insert
number of
days]-day
supply)

Mail-order
cost sharing
(up to a
[insert
number of
days]-day
supply)

Long-term
care (LTC)
cost sharing
(up to a
[insert
number of
days]-day
supply)

Out-of-network
cost sharing
(Coverage is limited
to certain situations;
see Chapter 3 for
details.)
(up to a [insert
number of days]day supply)

Cost-Sharing
Tier 1
([insert
description, e.g.,
generic drugs])

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Cost-Sharing
Tier 2
([insert
description])

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Cost-Sharing
Tier 3
([insert
description])

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Cost-Sharing
Tier 4
([insert
description])

[Insert
copay/
coinsurance]

[Insert copay/
coinsurance]

Tier

[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.
[Instructions to plans offering Value Based Insurance Design Model Test (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. Plans should include details of the exact
targeted reduced cost-sharing amount.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

Section 5.3

If your doctor prescribes less than a full month’s supply, you
may not have to pay the cost of the entire month’s supply

Typically, the amount you pay for a prescription drug covers a full month’s supply. 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).
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].]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 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:

Tier

Standard retail cost
sharing (innetwork) ([insert if
applicable: up to a]
[insert number of
days]-day supply)

Preferred retail cost
sharing (in-network)
([insert if applicable:
up to a] [insert
number of days]-day
supply)

Mail-order cost
sharing ([insert if
applicable: up to a]
[insert number of
days]-day supply)

Cost-Sharing Tier 1
([insert description])

[Insert copay/
coinsurance]

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]

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.]

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

Section 5.5

You stay in the Initial Coverage Stage until your [insert as
applicable: total drug costs for the year reach $[insert 2024
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 toward 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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

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 as 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

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

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.
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 on Immunization Practices (ACIP).
o Most adult Part D vaccinations are recommended by ACIP and cost you nothing.

2. Where you get the vaccine.

o The vaccine itself may be dispensed by a pharmacy or provided by the doctor’s
office.
3. Who gives you the vaccine.
o 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:

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.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 4 What you pay for your Part D prescription drugs

Situation 2:

Situation 3:

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

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 5.

•

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 5. 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 5:

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

2024 Evidence of Coverage for [insert 2024 plan name]

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

SECTION 1

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

Sometimes when you get 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, or you
may receive a bill from a provider. In these cases, you can ask our plan to pay you back (paying
you back is often called reimbursing you). There may be deadlines that you must meet to get
paid back. Please see Section 2 of this chapter.
Here are examples of situations in which you may need to ask our plan to pay you back. All of
these examples are types of coverage decisions (for more information about coverage decisions,
go to Chapter 7).
1. 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 3, Section 2.5 for a discussion of these circumstances.
2. When you pay the full cost for a prescription because you don’t have
your plan membership card with you
If you do not have your plan membership card with you, you can ask the pharmacy to call the
plan or look up your enrollment information. However, if the pharmacy cannot get the
enrollment information they need right away, you may need to pay the full cost of the
prescription yourself.
Save your receipt and send a copy to us when you ask us to pay you back for our share of the
cost.
3. When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not covered
for some reason.
•

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

•

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

2024 Evidence of Coverage for [insert 2024 plan name]

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

4. 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
drugs after your enrollment date, you can ask us to pay you back for our share of the costs.
You will need to submit paperwork for us to handle the reimbursement.
[Plans should insert additional circumstances under which they will accept a paper claim from a
member.]
All of the examples above are types of coverage decisions. This means that if we deny your
request for payment, you can appeal our decision. Chapter 7 of this document has information
about how to make an appeal.

SECTION 2

How to ask us to pay you back

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 receipt documenting the payment you have made. It’s a
good idea to make a copy of your 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.

•

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

Mail your request for payment together with any bills or paid receipts to us at this address:
[Insert address]

SECTION 3

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

Section 3.1

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

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

2024 Evidence of Coverage for [insert 2024 plan name]

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

•

If we decide that the drug is covered and you followed all the rules, we will pay for our
share of the cost. We will mail your reimbursement of our share of the cost to you. We
will send payment within 30 days after your request was received.

•

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

Section 3.2

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

If you think we have made a mistake in turning down your request for payment or 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 7 of this document.

CHAPTER 6:

Your rights and responsibilities

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 6 Your rights and responsibilities

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

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.
If you have any trouble getting information from our plan in a format that is accessible and
appropriate for you, please call to file a grievance with [insert plan contact information]. You
may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or
directly with the Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697.
Section 1.2

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

You have the right to get your prescriptions filled or refilled at any of our network pharmacies
without long delays. If you think that you are not getting your Part D drugs within a reasonable
amount of time, Chapter 7 tells what you can do.

2024 Evidence of Coverage for [insert 2024 plan name]

Chapter 6 Your rights and responsibilities

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
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 at the plan, and to get a copy of your
records. We are allowed to charge you a fee for making copies. You also have the right to ask us
to make additions or corrections to your medical records. If you ask us to do this, we will work
with your healthcare provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please
call Member Services.
[Note: Plans may insert custom privacy practices.]

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Section 1.4

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

[Plans may edit the section to reflect the types of alternate format materials available to plan
members and/or language primarily spoken in the plan service area.]
As a member of [insert 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 pharmacies. You have the right to get information
about the qualifications of the pharmacies in our network and how we pay the pharmacies
in our network.

•

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

•

Information about why something is not covered and what you can do about it.
Chapter 7 provides information on asking for a written explanation on why a Part D drug
is not covered or if your coverage is restricted. Chapter 7 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 give instructions about what is to be done if you are not
able to make medical decisions for yourself
[Note: Plans that would like to provide members with state-specific information about advanced
directives, including contact information for the appropriate state agency, may do so.]
Sometimes people become unable to make health care decisions for themselves due to accidents
or serious illness. You have the right to say what you want to happen if you are in this situation.
This means that, if you want to, you can:
•

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

•

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

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

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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 7 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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Section 1.7

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

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

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

•

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

•

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

•

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

For most of your drugs covered by the plan, you must pay your share of the cost
when you get the drug. [Plans that do not disenroll members for non-payment
may modify this section as needed.]

o If you are required to pay a late enrollment penalty, you must pay the penalty to
remain a member of the plan.
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 cannot remain a member of our plan.

•

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

CHAPTER 7:

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
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
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.

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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.
Is your problem or concern about your benefits or coverage?
(This includes problems about whether prescription drugs are covered or not, the way they
are covered, and problems related to payment for 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 7 at the end of this chapter: How to make a complaint
about quality of care, waiting times, customer service or other concerns.

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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
prescription drugs, including payments. This is the process you use for issues such as whether a
drug is covered or not and the way in which the drug is covered.
Asking for coverage decisions 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 prescription drugs.
We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay. In some cases, we might decide a drug is not covered or is no longer covered
by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
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 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.
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

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send a notice explaining why the request was dismissed and how to ask for a review of the
dismissal.
If we do not dismiss your case but say no to all or part of your Level 1 appeal, you can go on to a
Level 2 appeal. The Level 2 appeal is conducted by an independent review organization that is
not connected to us. 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 5 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 6 in this chapter explains the Level 3, 4,
and 5 appeals processes).
Section 4.2

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 or other prescriber can make a request for you. For Part D prescription
drugs, your doctor or other prescriber can request a coverage decision or a Level 1 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 another 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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SECTION 5

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

Section 5.1

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

Your benefits include coverage for many prescription drugs. To be covered, the drug must be
used for a medically accepted indication. (See Chapter 3 for more information about a medically
accepted indication.) For details about Part D drugs, rules, restrictions, and costs please see
Chapters 3 and 4.
•

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 5.2

•

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 5.2

•

[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 5.2

•

Asking to get pre-approval for a drug. Ask for a coverage decision. Section 5.4

•

Pay for a prescription drug you already bought. Ask us to pay you back. Section 5.4

If you disagree with a coverage decision we have made, you can appeal our decision.

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This section tells you both how to ask for coverage decisions and how to request an appeal.
Section 5.2

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 another 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 3 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 costsharing 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 lower cost-

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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 cost-sharing
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 cost-sharing
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 5.3

Important things to know about asking for exceptions

Your doctor must tell us the medical reasons
Your doctor or other prescriber must give us a statement that explains the medical reasons for
requesting an exception. For a faster decision, include this medical information from your doctor
or other prescriber when you ask for the exception.
Typically, our Drug List includes more than one drug for treating a particular condition. These
different possibilities are called alternative drugs. If an alternative drug would be just as
effective as the drug you are requesting and would not cause more side effects or other health
problems, we will generally not approve your request for an exception. [Plans with a formulary
structure (e.g., no tiers) that does not allow for tiering exceptions: omit this statement] If you ask
us for a tiering exception, we will generally not approve your request for an exception unless all
the alternative drugs in the lower cost-sharing tier(s) won’t work as well for you 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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Section 5.4

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 prescription 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 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 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 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 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 on to Level 1 of the appeals process.

Section 5.5

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

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 5.4 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 it.
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 5.6 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.

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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 5.6 explains the Level 2 appeal process.
•

If our answer is yes to part or all of what you requested, we must provide the
coverage 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 5.6

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

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decision regarding at-risk determination under our drug management program, we will
automatically forward your claim to the IRE.
•

We will send the information we have about your appeal to this organization. This
information is called your case file. You have the right to ask us for a copy of your
case file. [If a fee is charged, insert: We are allowed to charge you a fee for copying and
sending this information to you.]

•

You have a right to give the independent review organization additional information to
support your appeal.

Step 2: The independent review organization 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.

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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 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 6 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.

SECTION 6

Taking your appeal to Level 3 and beyond

Section 6.1

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.
•

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.

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 7

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

Section 7.1

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
care

•

Are you unhappy with the quality of the care you have received?

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

•

Have you been kept waiting too long by pharmacists? Or by our
Member Services or other staff at the plan?
o Examples include waiting too long on the phone, in the
waiting room, or getting a prescription.

Cleanliness

•

Are you unhappy with the cleanliness or condition of a pharmacy?

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 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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Section 7.2

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 7.3

Step-by-step: Making a complaint

Step 1: Contact us promptly – either by phone or in writing.
•

Usually, calling Member Services is the first step. If there is anything else you need to
do, Member Services will let you know.

•

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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Section 7.4

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 7.5

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 8:

Ending your membership in the plan

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SECTION 1

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 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 prescription drug plan.

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.

o – or – A Medicare health plan. A Medicare health plan is a plan offered by a
private company that contracts with Medicare to provide all of the Medicare Part
A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also
include Part D prescription drug coverage.
If you enroll in most Medicare health plans, you will be disenrolled from [insert
2024 plan name] when your new plan’s coverage begins. However, if you choose
a Private Fee-for-Service plan without Part D drug coverage, a Medicare Medical
Savings Account plan, or a Medicare Cost Plan, you can enroll in that plan and
keep [insert 2024 plan name] for your drug coverage. If you do not want to keep
our plan, you can choose to enroll in another Medicare prescription drug plan or
drop Medicare prescription drug coverage.

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100

Your membership will end in our plan when your new plan’s coverage begins on
January 1.

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 late enrollment
penalty if you join a Medicare drug plan later.
Section 2.2

In certain situations, you can end your membership during a
Special Enrollment Period

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):
o If you have moved out of your plan’s service area.

o [Revise bullet to use state-specific name, if applicable] If you have Medicaid.

o If you are eligible for “Extra Help” with paying for your Medicare prescriptions.
o If we violate our contract with you.

o If you are getting care in an institution, such as a nursing home or long-term care
(LTC) hospital.
o [Plans in states with PACE, insert: If you enroll in the Program of All-inclusive
Care for the Elderly (PACE). [National or multi-state plans when there is
variability in the availability of PACE insert: PACE is not available in all states.
If you would like to know if PACE is available in your state, please contact
Member Services.]]
o [Note: If you’re in a drug management program, you may not be able to change
plans. Chapter 3, 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
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1877-486-2048. 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:
o Another Medicare prescription drug plan.

o 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.


If you receive “Extra Help” from Medicare to pay for your
prescription drugs: If you switch to Original Medicare and do not enroll

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in a separate Medicare prescription drug plan, Medicare may enroll you in
a drug plan, unless you have opted out of automatic enrollment.
o – or – A Medicare health plan. A Medicare health plan is a plan offered by a
private company that contracts with Medicare to provide all of the Medicare Part
A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also
include Part D prescription drug coverage.


If you enroll in most Medicare health plans, you will automatically be
disenrolled from [insert 2024 plan name] when your new plan’s coverage
begins. However, if you choose a Private Fee-for-Service plan without
Part D drug coverage, a Medicare Medical Savings Account plan, or a
Medicare Cost Plan, you can enroll in that plan and keep [insert 2024 plan
name] for your drug coverage. If you do not want to keep our plan, you
can choose to enroll in another Medicare prescription drug plan or to drop
Medicare prescription drug coverage.

Your membership will usually end on the first day of the month after we receive your
request to change your plan.

•

Section 2.3

Where can you get more information about when you can end
your membership?

If you have any questions about ending your membership you can:
•

Call Member Services.

•

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:
•

Another Medicare
prescription drug plan.

This is what you should do:
•
•

Enroll in the new Medicare prescription drug plan
between October 15 and December 7.
You will automatically be disenrolled from [insert
2024 plan name] when your new plan’s coverage
begins.

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Chapter 8 Ending your membership in the plan

If you would like to switch from
our plan to:
•

A Medicare health plan.

This is what you should do:
•

•

Original Medicare without
a separate Medicare
prescription drug plan.

•

SECTION 4

102

Enroll in the Medicare health plan by December 7.
With most Medicare health plans, you will
automatically be disenrolled from [insert 2024
plan name] when your new plan’s coverage
begins.
However, if you choose a Private Fee-For-Service
plan without Part D drug coverage, a Medicare
Medical Savings Account plan, or a Medicare
Cost Plan, you can enroll in that new plan and
keep [insert 2024 plan name] for your drug
coverage. If you want to leave our plan, you must
either enroll in another Medicare prescription
drug plan or ask to be disenrolled. To ask to be
disenrolled, you must send us a written request
(contact Member Services if you need more
information on how to do this) or contact
Medicare at 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week (TTY users
should call 1-877-486-2048).
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.

Until your membership ends, you must keep getting
your drugs through our plan

Until your membership ends, and your new Medicare coverage begins, you must continue to get
your prescription drugs through our plan.
•

Continue to use our network pharmacies [insert if appropriate or mail order] to get
your prescriptions filled.

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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 or Part B (or both).

•

If you move out of our service area.

•

If you are away from our service area for more than 12 months.
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.

•

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.)

•

[Omit bullet if not applicable] If you continuously behave in a way that is disruptive and
makes it difficult for us to provide care for you and other members of our plan. (We
cannot make you leave our plan for this reason unless we get permission from Medicare
first.)

•

[Omit bullet and sub-bullet if not applicable] If you let someone else use your
membership card to get prescription drugs. (We cannot make you leave our plan for this
reason unless we get permission from Medicare first.)
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.

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•

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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

[Insert 2024 plan name] is not allowed to ask you to leave our plan for any health-related reason.
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 file a grievance or can make a complaint about our
decision to end your membership.

CHAPTER 9:

Legal notices

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Chapter 9 Legal notices

SECTION 1

106

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 prescription drug plans, like our plan, must
obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the
Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities
Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get
Federal funding, and any other laws and rules that apply for any other reason.
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 at
https://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 prescription drugs 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 prescription drug plan sponsor, will
exercise the same rights of recovery that the Secretary exercises under CMS regulations in
subparts B through D of part 411 of 42 CFR and the rules established in this section supersede
any State laws.
[Note: You may include other legal notices, such as a notice of member non-liability 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 10:

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.]
Appeal – An appeal is something you do if you disagree with our decision to deny a request for
coverage of prescription drugs or payment for drugs you already received.
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.
Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical
company that originally researched and developed the drug. Brand name drugs have the same
active-ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until after the
patent on the brand name drug has expired.
Catastrophic Coverage Stage – The stage in the Part D Drug Benefit 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 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.
Copayment (or copay) – An amount you may be required to pay as your share of the cost for a
prescription drug. A copayment is a set amount (for example $10), rather than a percentage.

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Cost Sharing – Cost sharing refers to amounts that a member has to pay when drugs are
received. [Insert if plan has a premium: (This is in addition to the plan’s monthly premium.)]
Cost sharing includes any combination of the following three types of payments: (1) any
deductible amount a plan may impose before drugs are covered; (2) any fixed copayment amount
that a plan requires when a specific drug is received; or (3) any coinsurance amount, a
percentage of the total amount paid for a drug, that a plan requires when a specific drug is
received.
[Delete if plan does not use tiers] Cost-Sharing Tier – Every drug on the list of covered drugs is
in one of [insert number of tiers] cost-sharing tiers. In general, the higher the cost-sharing tier,
the higher your cost for the drug.
Coverage Determination – A decision about whether a drug prescribed for you is covered by
the plan and the amount, if any, you are required to pay for the prescription. In general, if you
bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered
under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask
for a formal decision about the coverage. Coverage determinations are called coverage decisions
in this document.
Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan.
Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare’s standard
prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty if they decide to enroll
in Medicare prescription drug coverage later.
Daily cost-sharing rate – A daily cost-sharing rate may apply when your doctor prescribes less
than a full month’s supply of certain drugs for you and you are required to pay a copayment. A
daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Here
is an example: If your copayment for a one-month supply of a drug is $30, and a one-month’s
supply in your plan is 30 days, then your daily cost-sharing rate is $1 per day.
Deductible – The amount you must pay for 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.

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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.
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.
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.

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List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by
the plan.
Low Income Subsidy (LIS) – See “Extra Help.”
Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical
costs for some people with low incomes and limited resources. 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.
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 (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. The term
Medicare-Covered Services does not include the extra benefits, such as vision, dental or hearing,
that a Medicare Advantage plan may offer.
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).

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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.
Original Medicare (Traditional Medicare or Fee-for-service Medicare) – Original Medicare is
offered by the government, and not a private health plan like Medicare Advantage Plans and
prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care providers payment amounts established by Congress.
You can see any doctor, hospital, or other health care provider that accepts Medicare. You must
pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your
share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical
Insurance) and is available everywhere in the United States.
Out-of-Network Pharmacy – A pharmacy that 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-Pocket Costs – See the definition for cost sharing above. A member’s cost-sharing
requirement to pay for a portion of drugs received is also referred to as the member’s out-ofpocket 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. [National or multistate plans when there is variability in the availability of PACE insert: PACE is not available in
all states. If you would like to know if PACE is available in your state, please contact Member
Services.]]
Part C – see Medicare Advantage (MA) Plan.

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Chapter 10 Definitions of important words

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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.
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.]
Premium – The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
Prior Authorization – Approval in advance to get certain drugs. [Plans may delete applicable
sentences if it does not require prior authorization for any drugs.] Covered drugs that need prior
authorization are marked in the formulary.
Quality Improvement Organization (QIO) – A group of practicing doctors and other health
care experts paid by the Federal government to check and improve the care given to Medicare
patients.
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.
Service Area – A geographic area where you must live to join a particular prescription drug
plan. The plan may disenroll you if you permanently move out of the plan’s service area.
Special Enrollment Period – A set time when members can change their health or drug plans or
return to Original Medicare. Situations in which you may be eligible for a Special Enrollment
Period include: if you move outside the service area, if you are getting “Extra Help” with your
prescription drug costs, if you move into a nursing home, or if we violate our contract with you.

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[Include this definition only if Part D plan has pharmacies that offer preferred cost sharing in
addition to those offering standard cost sharing:
Standard Cost Sharing – Standard cost sharing is cost sharing other than preferred cost sharing
offered at a network pharmacy.]
Step Therapy – A utilization tool that requires you to first try another drug to treat your medical
condition before we will cover the drug your physician may have initially prescribed.
Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people
with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are
not the same as Social Security benefits.
[This is the back cover for the EOC. Plans may add a logo and/or photographs, as long as these
elements do not make it difficult for members to find and read the plan contact information.]
[Insert 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.

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115

[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 Medicare Prescription Drug Plan (PDP) Evidence of Coverage (EOC) Templates
Subject	2023 Medicare Prescription Drug Plan (PDP) Evidence of Coverage (EOC) Templates
Author	Centers for Medicare & Medicaid Services
File Modified	2023-04-07
File Created	2023-04-07