OMB Approval (Approved 03/2014) WellCare 2014

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1 January 1 December 31, 2015 Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of WeCare Simpe (PDP) This booket gives you the detais about your Medicare prescription drug coverage from January 1 December 31, It expains how to get coverage for the prescription drugs you need. This is an important ega document. Pease keep it in a safe pace. This pan, WeCare Simpe (PDP), is offered by Windsor Heath Pan, Inc. or Stering Life Insurance Company. (When this Evidence of Coverage says we, us, or our, it means Windsor Heath Pan, Inc. or Stering Life Insurance Company. When it says pan or our pan, it means WeCare Simpe (PDP).) WeCare (PDP) is a Medicare-approved Part D sponsor. Enroment in WeCare (PDP) depends on contract renewa. This information is avaiabe for free in other anguages. Pease contact our Customer Service number at for additiona information. (TTY users shoud ca ). Hours are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. Customer Service aso has free anguage interpreter services avaiabe for non-engish speakers. Esta información se encuentra disponibe en otros idiomas gratis. Por favor comuníquese con nuestro Servicio a Ciente amando a , para información adiciona. (Los usuarios de TTY deben amar a ). E horario de atención es de unes a viernes de 8 am a 8 pm. Entre e 1 de Octubre y e 14 de Febrero, os representantes estarán disponibes de unes a domingo de 8 am a 8 pm. Servicio a ciente también tiene servicios disponibes de interpretación a otros idiomas gratis para personas que no haban ingés. Customer Service can aso give you information in Braie, Audio CD or other aternate formats if you need it. Benefits, formuary, pharmacy network, premium, deductibe, and/or co-payments/coinsurance may change on January 1, Y0070_NA026723_PDP_CMB_ENG CMS Accepted Form CMS ANOC/EOC OMB Approva (Approved 03/2014) WeCare 2014 NA5SIMEOC60881E_0614

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3 2015 Evidence of Coverage for WeCare Simpe (PDP) Muti-anguage Interpreter Services Engish: We have free interpreter services to answer any q니estions yᄋ니 may have abᄋ니t ᄋ니r heath or dnjg pan. To get an interpreter, j니st ca 니s at Someone who speaks Engish can hep you. This is a f ee service. Spanish: Tenemos servicios de intérprete sin costo ag니no para responder с니aq니ier preg니nta q니e p니eda tener sobre n니estro pian de sahjd 0 medicamentos. Para habar con 니n intèrprete, por favor ame a Ag니ien q니e habe españo e podrá ay 니dar. Este es 니n servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 о 如 果 您 需 要 此 翻 译 服 务, 请 致 电 о 我 们 的 中 文 工 作 ᄉ 员 很 乐 意 帮 助 您 о 这 是 一 项 免 费 服 务 о Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 , 我 們 講 中 文 的 ᄉ 員 將 樂 意 為 您 提 供 幫 助 о 這 是 一 項 免 費 服 務 Tagaog: Mayroon kaming ibreng serbisyo sa pagsasaing-wika 니pang masagot ang amjmang mga katan니ngan ninyo hinggi sa aming panong pangkausugan 0 panggamot. Upang makakuha ng tagasaing-wika, tawagan amang kami sa Maaari kayong t 니hjngan ng isang nakakapagsaita ng Tagaog. Ito ay ibreng serbisyo. French: No니s proposons des services grat니its d'interprétation p ᄋ니г répondre à toutes vos questions reatives à notre régime de santé ᄋ니 d'ass니rance-médicaments. pᄋ니г accéder a니 service d'interprétation, i Vᄋ니s s니ffit de nᄋ니s appeer a니 Un inte oc니te니r parant Français pᄋ니 a Vᄋ니s aider. Ce service est g at니it. Y0070 NA PDP INS MLT CMS Accepted WeCare Simpe (PDP)

4 2015 Evidence of Coverage for WeCare Simpe (PDP) Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả ời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây à dịch vụ miễn phí German: Unser kostenoser Dometscherservice beantwortet Ihren Fragen 고니 니 nse em Ges니ndheits- 니nd Arzneimittepan. Unsere Dometscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhefen. Dieser Service ist kostenos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의 해 주십 시 오. 한국어 를 하는 담당자가 도와 드릴 것 입 니 다. 이 서 비 스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментногᄋ плана, вы можете воспользоваться нашими бесплатными услугами перевод니иков. 니тобы воспользоваться услугами перевод니ика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по-русски. Данная услуга бесплатная. Arabic: ^Jc. \\ Lủ] j, 시Ị < (JjLtJJ diuii ự (_jc. ᄂы! 2 ń -4. 시ỉ CLâAk Lij Ả요ik 1 ᄂa ᄂ 少 으4i>\\ 7851 _ 462 _ 008 _ 1 ^ ᄂ)ᄂ시성п ᄂg 9JJÚ i사 Hindi: 쩨몬예'식ìoHi 3ÏÏ4%며t fr44^ĩ%згамы#7í^nr Ẹỉĩừ 4RT 향ᅲ유RTT ^TTT зчдаг f. ^ : n ïï 4Ĩ4Ĩ #7 í^nr, ẸỈỊ ^îf ciiííd 3frf^tsìdd t зттч^г^rkttậ". Itaian: È disponibie 니n servizio di interpretariato gratuito per rispondere a event니ai domande s니ᅵ nostro piano sanitario e farmace 니tico. Per 니n interprete, contattare i mjmerᄋ Un nostro incaricato che para Itaianovi fornirà 'assistenza necessaria. È 니n servizio grat니ito.

5 2015 Evidence of Coverage for WeCare Simpe (PDP) Portugués: Dispomos de serviços de inte p etaçãᄋ g at니itos pa a responder a q니aq니er q니estão q니e tenha acerca do nosso pano de saúde ᄋ니 de medicação. Para obter 니이 intérprete, contacte-nos através do número Irá encontrar aguém que fae o idioma Português pa a o ajudar Este serviço é gratuito. French Creoe: No니 genyen sévis entèprèt gratis pᄋ니 reponn tᄋ니t kesyon ᄋ니 ta genyen konsènan pan medika oswa dwôg n ᄋ니 an. pᄋ니 jwenn yon entèprèt, jis ee nᄋ니 nan Yon mᄋ니n ki pae Kreyò kapab ede w. Sa a se yon sèvis ki gratis. Poish: Umo 之 iwiamy bezpłatne skorzystanie z 니sł니g tł니macza 니stnegᄋ, który pomo 之 e w 니zyskani니 odpowiedzi na temat panu zdrowotnego hjb dawkowania eków. Aby skorzystać z pomocy tł니macza znającego język poski, naie 之 y zadzwonić pod numer Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プラ ンに 関 する ご 質 問 にお 答 えする た めに 無 料 の 通 訳 サービ ᄌ があります ございます о 通 訳 を ご 用 命 になる には にお 電 話 く ださい 0 日 本 語 を 話 すᄉ 者 が 支 援 いた ᄂ ます これは 無 料 のサー ビᄌ です 0

6 2015 Evidence of Coverage for WeCare Simpe (PDP) Tabe of Contents 2015 Evidence of Coverage Tabe of Contents 1 This ist of chapters and page numbers is your starting point. For more hep in finding information you need, go to the first page of a chapter. You wi find a detaied ist of topics at the beginning of each chapter. Chapter 1. Getting started as a member...3 Expains what it means to be in a Medicare prescription drug pan and how to use this booket. Tes about materias we wi send you, your pan premium, your pan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources...20 Tes you how to get in touch with our pan (WeCare Simpe (PDP)) and with other organizations incuding Medicare, the State Heath Insurance Assistance Program (SHIP), the Quaity Improvement Organization, Socia Security, Medicaid (the state heath insurance program for peope with ow incomes), programs that hep peope pay for their prescription drugs, and the Rairoad Retirement Board. Chapter 3. Using the pan s coverage for your Part D prescription drugs Expains rues you need to foow when you get your Part D drugs. Tes how to use the pan s List of Covered Drugs (Formuary) to find out which drugs are covered. Tes which kinds of drugs are not covered. Expains severa kinds of restrictions that appy to coverage for certain drugs. Expains where to get your prescriptions fied. Tes about the pan s programs for drug safety and managing medications. Chapter 4. What you pay for your Part D prescription drugs...64 Tes about the four stages of drug coverage (Deductibe Stage, Initia Coverage Period, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Expains the five cost-sharing tiers for your Part D drugs and tes what you must pay for a drug in each cost-sharing tier. Tes about the ate enroment penaty. Chapter 5. Asking us to pay our share of the costs for covered drugs...89

7 2015 Evidence of Coverage for WeCare Simpe (PDP) Tabe of Contents 2 Chapter 6. Chapter 7. Expains when and how to send a bi to us when you want to ask us to pay you back for our share of the cost for your covered drugs. Your rights and responsibiities...95 Expains the rights and responsibiities you have as a member of our pan. Tes what you can do if you think your rights are not being respected. What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Tes you step-by-step what to do if you are having probems or concerns as a member of our pan. Expains how to ask for coverage decisions and make appeas if you are having troube getting the prescription drugs you think are covered by our pan. This incudes asking us to make exceptions to the rues and/or extra restrictions on your coverage. Expains how to make compaints about quaity of care, waiting times, customer service, and other concerns. Chapter 8. Ending your membership in the pan Expains when and how you can end your membership in the pan. Expains situations in which our pan is required to end your membership. Chapter 9. Lega notices Incudes notices about governing aw and about non-discrimination. Chapter 10. Definitions of important words Expains key terms used in this booket.

8 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 3 Chapter 1. Getting started as a member SECTION 1 Introduction... 5 Section 1.1 You are enroed in WeCare Simpe (PDP), which is a Medicare Prescription Drug Pan... 5 Section 1.2 What is the Evidence of Coverage booket about?... 5 Section 1.3 What does this Chapter te you?... 5 Section 1.4 What if you are new to WeCare Simpe (PDP)?... 6 Section 1.5 Lega information about the Evidence of Coverage... 6 SECTION 2 What makes you eigibe to be a pan member?... 6 Section 2.1 Your eigibiity requirements... 7 Section 2.2 What are Medicare Part A and Medicare Part B?... 7 Section 2.3 Here is the pan service area for WeCare Simpe (PDP)... 7 SECTION 3 What other materias wi you get from us?... 8 Section 3.1 Your pan membership card Use it to get a covered prescription drugs... 8 Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network. 9 Section 3.3 The pan s List of Covered Drugs (Formuary)... 9 Section 3.4 The Part D Expanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs...10 SECTION 4 Your monthy premium for WeCare Simpe (PDP) Section 4.1 How much is your pan premium? Section 4.2 There are severa ways you can pay your pan premium Section 4.3 Can we change your monthy pan premium during the year? SECTION 5 Pease keep your pan membership record up to date Section 5.1 How to hep make sure that we have accurate information about you... 16

9 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 4 SECTION 6 We protect the privacy of your persona heath information Section 6.1 We make sure that your heath information is protected SECTION 7 How other insurance works with our pan Section 7.1 Which pan pays first when you have other insurance?... 18

10 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 5 SECTION 1 Section 1.1 Introduction You are enroed in WeCare Simpe (PDP), which is a Medicare Prescription Drug Pan You are covered by Origina Medicare for your heath care coverage, and you have chosen to get your Medicare prescription drug coverage through our pan, WeCare Simpe (PDP). There are different types of Medicare pans. Our pan is a Medicare prescription drug pan (PDP). Like a Medicare pans, this Medicare prescription drug pan is approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booket about? This Evidence of Coverage booket tes you how to get your Medicare prescription drug coverage through our pan. This booket expains your rights and responsibiities, what is covered, and what you pay as a member of the pan. This pan, WeCare Simpe (PDP), is offered by Windsor Heath Pan, Inc. or Stering Life Insurance Company. (When this Evidence of Coverage says we, us, or our, it means Windsor Heath Pan, Inc. or Stering Life Insurance Company. When it says pan or our pan, it means WeCare Simpe (PDP).) The word coverage and covered drugs refers to the prescription drug coverage avaiabe to you as a member of WeCare Simpe (PDP). Section 1.3 What does this Chapter te you? Look through Chapter 1 of this Evidence of Coverage to earn: What makes you eigibe to be a pan member? What is your pan s service area? What materias wi you get from us? What is your pan premium and how can you pay it? How do you keep the information in your membership record up to date?

11 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 6 Section 1.4 What if you are new to WeCare Simpe (PDP)? If you are a new member, then it s important for you to earn what the pan s rues are and what coverage is avaiabe to you. We encourage you to set aside some time to ook through this Evidence of Coverage booket. If you are confused or concerned or just have a question, pease contact our pan s Customer Service (phone numbers are printed on the back cover of this booket). Section 1.5 Lega information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how our pan covers your care. Other parts of this contract incude your enroment form, the List of Covered Drugs (Formuary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes caed riders or amendments. The contract is in effect for months in which you are enroed in our pan between January 1, 2015 and December 31, Each caendar year, Medicare aows us to make changes to the pans that we offer. This means we can change the costs and benefits of our pan after December 31, We can aso choose to stop offering the pan, or to offer it in a different service area, after December 31, Medicare must approve our pan each year Medicare (the Centers for Medicare & Medicaid Services) must approve our pan each year. You can continue to get Medicare coverage as a member of our pan as ong as we choose to continue to offer the pan and Medicare renews its approva of the pan. SECTION 2 What makes you eigibe to be a pan member?

12 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 7 Section 2.1 Your eigibiity requirements You are eigibe for membership in our pan as ong as: You ive in our geographic service area (Section 2.3 beow describes our service area) -- and-- you have Medicare Part A or Medicare Part B (or you have both Part A and Part B) Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generay heps cover services provided by hospitas (for inpatient services, skied nursing faciities, or home heath agencies). Medicare Part B is for most other medica services (such as physician s services and other outpatient services) and certain items (such as durabe medica equipment and suppies). Section 2.3 Here is the pan service area for WeCare Simpe (PDP) Athough Medicare is a Federa program, our pan is avaiabe ony to individuas who ive in our pan service area. To remain a member of our pan, you must continue to reside in the pan service area. The service area is described beow. Our service area incudes these states: Region State(s) 07 Virginia 09 South Caroina 12 Aabama & Tennessee 18 Missouri 19 Arkansas 20 Mississippi Region State(s) 21 Louisiana 22 Texas 23 Okahoma 30 Oregon & Washington 31 Idaho & Utah

13 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 8 We offer coverage in severa states. However, there may be cost or other differences between the pans we offer in each state. If you move out of state and into a state that is sti within our service area, you must ca Customer Service in order to update your information. If you move into a state outside of our service area, you cannot remain a member of our pan. Pease ca Customer Service to find out if we have a pan in your new state. If you pan to move out of the service area, pease contact Customer Service (phone numbers are printed on the back cover of this booket). When you move, you wi have a Specia Enroment Period that wi aow you to enro in a Medicare heath or drug pan that is avaiabe in your new ocation. It is aso important that you ca Socia Security if you move or change your maiing address. You can find phone numbers and contact information for Socia Security in Chapter 2, Section 5. SECTION 3 Section 3.1 What other materias wi you get from us? Your pan membership card Use it to get a covered prescription drugs Whie you are a member of our pan, you must use your membership card for our pan for prescription drugs you get at network pharmacies. Here s a sampe membership card to show you what yours wi ook ike: Pease carry your card with you at a times and remember to show your card when you get covered drugs. If your pan membership card is damaged, ost, or stoen,

14 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 9 ca Customer Service right away and we wi send you a new card. (Phone numbers for Customer Service are printed on the back cover of this booket.) You may need to use your red, white, and bue Medicare card to get covered medica care and services under Origina Medicare. Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network What are network pharmacies? Our Pharmacy Directory gives you a compete ist of our network pharmacies that means a of the pharmacies that have agreed to fi covered prescriptions for our pan members. Why do you need to know about network pharmacies? You can use the Pharmacy Directory to find the network pharmacy you want to use. The Pharmacy Directory incudes Retai, Chain, Mai Service, Long-Term Care, Home Infusion, Indian Heath Service and Speciaty pharmacies. This is important because, with few exceptions, you must get your prescriptions fied at one of our network pharmacies if you want our pan to cover (hep you pay for) them. The Pharmacy Directory wi aso te you which of the pharmacies in our network have preferred cost-sharing, which may be ower than the standard cost-sharing offered by other network pharmacies. If you don t have the Pharmacy Directory, you can get a copy from Customer Service (phone numbers are printed on the back cover of this booket). At any time, you can ca Customer Service to get up-to-date information about changes in the pharmacy network. You can aso find this information on our website at Section 3.3 The pan s List of Covered Drugs (Formuary) The pan has a List of Covered Drugs (Formuary). We ca it the Drug List for short. It tes which Part D prescription drugs are covered by our pan. The drugs on this ist are seected by the pan with the hep of a team of doctors and

15 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 10 pharmacists. The ist must meet requirements set by Medicare. Medicare has approved the WeCare Simpe (PDP) Drug List. The Drug List aso tes you if there are any rues that restrict coverage for your drugs. We wi send you a copy of the Drug List. The Drug List we send to you incudes information for the covered drugs that are most commony used by our members. However, we cover additiona drugs that are not incuded in the printed Drug List. If one of your drugs is not isted in the Drug List, you shoud visit our website or contact Customer Service to find out if we cover it. To get the most compete and current information about which drugs are covered, you can visit the pan s website ( or ca Customer Service (phone numbers are printed on the back cover of this booket). Section 3.4 The Part D Expanation of Benefits (the Part D EOB ): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we wi send you a summary report to hep you understand and keep track of payments for your Part D prescription drugs. This summary report is caed the Part D Expanation of Benefits (or the Part D EOB ). The Part D Expanation of Benefits tes you the tota amount you, or others on your behaf, have spent on your Part D prescription drugs and the tota amount we have paid for each of your Part D prescription drugs during the month. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about the Part D Expanation of Benefits and how it can hep you keep track of your drug coverage. A Part D Expanation of Benefits summary is aso avaiabe upon request. To get a copy, pease contact Customer Service (phone numbers are printed on the back cover of this booket). SECTION 4 Your monthy premium for WeCare Simpe (PDP) Section 4.1 How much is your pan premium? As a member of our pan, you pay a monthy pan premium. The tabe beow shows the monthy pan premium amount for each state we serve. In addition, you must

16 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 11 continue to pay your Medicare Part B premium (uness your Part B premium is paid for you by Medicaid or another third party). State Monthy Premiums AL $26.90 AR $29.70 ID $37.70 LA $29.60 MO $34.70 MS $33.30 OK $38.00 State Monthy Premiums OR $31.70 SC $33.80 TN $26.90 TX $30.40 UT $37.70 VA $31.90 WA $31.70 In some situations, your pan premium coud be ess There are programs to hep peope with imited resources pay for their drugs. These incude Extra Hep and State Pharmaceutica Assistance Programs. Chapter 2, Section 7 tes more about these programs. If you quaify, enroing in the program might ower your monthy pan premium. If you are aready enroed and getting hep from one of these programs, the information about premiums in this Evidence of Coverage may not appy to you. We have incuded a separate insert, caed the Evidence of Coverage Rider for Peope Who Get Extra Hep Paying for Prescription Drugs (aso known as the Low Income Subsidy Rider or the LIS Rider ), which tes you about your drug coverage. If you don t have this insert, pease ca Customer Service and ask for the LIS Rider. (Phone numbers for Customer Service are printed on the back cover of this booket.) In some situations, your pan premium coud be more In some situations, your pan premium coud be more than the amount isted above in Section 4.1. Some members are required to pay a ate enroment penaty because they did not join a Medicare drug pan when they first became eigibe or because they had a continuous period of 63 days or more when they didn t have creditabe prescription drug coverage. ( Creditabe means the drug coverage is expected to pay, on average, at east as much as Medicare s standard prescription

17 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 12 drug coverage.) For these members, the ate enroment penaty is added to the pan s monthy premium. Their premium amount wi be the monthy pan premium pus the amount of their ate enroment penaty. If you are required to pay the ate enroment penaty, the amount of your penaty depends on how ong you waited before you enroed in drug coverage or how many months you were without drug coverage after you became eigibe. Chapter 4, Section 9, expains the ate enroment penaty. If you have a ate enroment penaty and do not pay it, you coud be disenroed from the pan. Many members are required to pay other Medicare premiums In addition to paying the monthy pan premium, many members are required to pay other Medicare premiums. Some pan members (those who aren t eigibe for premium-free Part A) pay a premium for Medicare Part A. And most pan members pay a premium for Medicare Part B. Some peope pay an extra amount for Part D because of their yeary income, this is known as Income Reated Monthy Adjustment Amounts, aso known as IRMAA. If your income is $85,000 or above for an individua (or married individuas fiing separatey) or $170,000 or above for married coupes, you must pay an extra amount directy to the government (not the Medicare pan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you wi be disenroed from the pan and ose prescription drug coverage. If you have to pay an extra amount, Socia Security, not your Medicare pan, wi send you a etter teing you what that extra amount wi be. For more information about Part D premiums based on income, go to Chapter 4, Section 10, of this booket. You can aso visit on the Web or ca MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca Or you may ca Socia Security at TTY users shoud ca Your copy of Medicare & You 2015 gives information about the Medicare premiums in the section caed 2015 Medicare Costs. This expains how the Medicare Part B and Part D premiums differ for peope with different incomes.

18 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 13 Everyone with Medicare receives a copy of Medicare & You each year in the fa. Those new to Medicare receive it within a month after first signing up. You can aso downoad a copy of Medicare & You 2015 from the Medicare website ( Or, you can order a printed copy by phone at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users ca Section 4.2 There are severa ways you can pay your pan premium There are five ways you can pay your pan premium. The premium payment options were isted on the enroment appication, and you chose a method of payment when you enroed. You may change the premium payment option you choose during the year by caing Customer Service and submitting the required form. If you decide to change the way you pay your premium, it can take up to three months for your new payment method to take effect. Whie we are processing your request for a new payment method, you are responsibe for making sure that your pan premium is paid on time. Option 1: You can pay by check You may decide to pay your monthy pan premium directy to our pan with a check or money order. Premium coupons wi be maied after confirmation of enroment. You may request repacement coupons by caing Customer Service. Payments are due by the 28th of each month for coverage of the current month. Checks must be made payabe to WeCare. Be sure to incude your biing payment coupon with your check to ensure the appropriate credit is appied to your account and send to the foowing address, which is aso isted in our payment coupons: WeCare, P.O. Box 78230, Phoenix, AZ Any checks made payabe to another entity (e.g., U.S. Department of Heath and Human Services (HHS) or the Centers for Medicare & Medicaid Services (CMS)) wi be returned to you. The pan reserves the right to charge a $30 administrative fee associated with checks returned for non-sufficient funds (NSF). This fee does not incude any additiona fees that may be appied by your bank.

19 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 14 Option 2: You can pay onine by using our website with a credit card or your checking or savings bank information Instead of maiing a check each month, you can have your monthy premium deducted from your checking or savings account or even charged directy to your credit card. These payments can be a one-time ony payment or set up as a repeating monthy deduction. To make your payment onine: 1. Visit our website at 2. Seect Member Login and enter your user id and password. If you don t have a user id or password, cick on Register to create one. 3. Cick on the Pay Your Premium ink under the Member Toobox. 4. Once you cick on this ink, you wi be abe to make a payment. Option 3: You can have Automatic Withdrawas or Eectronic Funds Transfer (EFT) Instead of paying by check, you may have your monthy pan premium automaticay withdrawn from your checking or savings account. Automatic withdrawas occur monthy and wi be deducted between the 24th and 28th of each month for the current month. You may access the form on our website at or ca our Customer Service department at the number printed on the back cover of this booket to request an EFT form. If you woud ike to have your monthy pan premiums deducted from your bank account instead of receiving a bi each month, pease foow the instructions on the form and compete and return the form to us. Once we receive your paperwork, the process may take up to two months to take effect. You shoud keep paying your monthy bi unti notified by mai of the actua month that EFT withdrawas wi start. The pan reserves the right to charge a $30 administrative fee associated with EFT withdrawas returned for non-sufficient funds (NSF). This fee does not incude any additiona fees that may be appied by your bank.

20 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 15 Option 4: You can have the pan premium taken out of your monthy Rairoad Retirement Board check You can have the pan premium taken out of your monthy Rairoad Retirement Board check. Contact Customer Service for more information on how to pay your monthy pan premium this way. We wi be happy to set this up. (Phone numbers for Customer Service are printed on the back cover of this booket.) Option 5: You can have the pan premium taken out of your monthy Socia Security check You can have the pan premium taken out of your monthy Socia Security check. Contact Customer Service for more information on how to pay your monthy pan premium this way. We wi be happy to hep you set this up. (Phone numbers for Customer Service are printed on the back cover of this booket.) What to do if you are having troube paying your pan premium Your pan premium is due in our office by the 28th of the month. If we have not received your premium by the 28th, we wi send you a notice teing you that your pan membership wi end if we do not receive your premium payment within two (2) caendar months from the 1st day of the coverage month. If you are having troube paying your premium on time, pease contact Customer Service to see if we can direct you to programs that wi hep with your pan premium. (Phone numbers for Customer Service are printed on the back cover of this booket.) If we end your membership with the pan because you did not pay your premiums, and you don t currenty have prescription drug coverage then you may not be abe to receive Part D coverage unti the foowing year if you enro in a new pan during the annua enroment period. During the annua enroment period, you may either join a stand-aone prescription drug pan or a heath pan that aso provides drug coverage. (If you go without creditabe drug coverage for more than 63 days, you may have to pay a ate enroment penaty for as ong as you have Part D coverage.) If we end your membership because you did not pay your premiums, you wi sti have heath coverage under Origina Medicare. At the time we end your membership, you may sti owe us for premiums you have not paid. We have the right to pursue coection of the premiums you owe. In the future, if

21 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 16 you want to enro again in our pan (or another pan that we offer), you wi need to pay the amount you owe before you can enro. If you think we have wrongfuy ended your membership, you have a right to ask us to reconsider this decision by making a compaint. Chapter 7, Section 7 of this booket tes how to make a compaint. If you had an emergency circumstance that was out of your contro and it caused you to not be abe to pay your premiums within our grace period, you can ask Medicare to reconsider this decision by caing MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca Section 4.3 Can we change your monthy pan premium during the year? No. We are not aowed to change the amount we charge for the pan s monthy pan premium during the year. If the monthy pan premium changes for next year we wi te you in September and the change wi 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 eigibe for the "Extra Hep" program or if you ose your eigibiity for the "Extra Hep" program during the year. If a member quaifies for "Extra Hep" with their prescription drug costs, the "Extra Hep" program wi pay part of the member s monthy pan premium. So a member who becomes eigibe for "Extra Hep" during the year woud begin to pay ess towards their monthy premium. And a member who oses their eigibiity during the year wi need to start paying their fu monthy premium. You can find out more about the "Extra Hep" program in Chapter 2, Section 7. SECTION 5 Pease keep your pan membership record up to date Section 5.1 How to hep make sure that we have accurate information about you Your membership record has information from your enroment form, incuding your address and teephone number. It shows your specific pan coverage. The pharmacists in the pan 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 hep us keep your information up to date. Let us know about these changes: Changes to your name, your address, or your phone number

22 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 17 Changes in any other medica or drug insurance coverage you have (such as from your empoyer, your spouse s empoyer, workers compensation, or Medicaid) If you have any iabiity caims, such as caims from an automobie accident If you have been admitted to a nursing home If your designated responsibe party (such as a caregiver) changes If any of this information changes, pease et us know by caing Customer Service (phone numbers are printed on the back cover of this booket). It is aso important to contact Socia Security if you move or change your maiing address. You can find phone numbers and contact information for Socia Security in Chapter 2, Section 5. Read over the information we send you about any other insurance coverage you have That s because we must coordinate any other coverage you have with your benefits under our pan. (For more information about how our coverage works when you have other insurance, see Section 7 in this chapter.) Once each year, we wi send you a etter that ists any other medica or drug insurance coverage that we know about. Pease read over this information carefuy. 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 isted, pease ca Customer Service (phone numbers are printed on the back cover of this booket). In some cases, we may need to ca you to verify the information we have on fie. SECTION 6 Section 6.1 We protect the privacy of your persona heath information We make sure that your heath information is protected Federa and state aws protect the privacy of your medica records and persona heath information. We protect your persona heath information as required by these aws. For more information about how we protect your persona heath information, pease go to Chapter 6, Section 1.4 of this booket. SECTION 7 How other insurance works with our pan

23 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 18 Section 7.1 Which pan pays first when you have other insurance? When you have other insurance (ike empoyer group heath coverage), there are rues set by Medicare that decide whether our pan or your other insurance pays first. The insurance that pays first is caed the primary payer and pays up to the imits of its coverage. The one that pays second, caed the secondary payer, ony pays if there are costs eft uncovered by the primary coverage. The secondary payer may not pay a of the uncovered costs. These rues appy for empoyer or union group heath pan coverage: If you have retiree coverage, Medicare pays first. If your group heath pan coverage is based on your or a famiy member s current empoyment, who pays first depends on your age, the number of peope empoyed by your empoyer, and whether you have Medicare based on age, disabiity, or End-stage Rena Disease (ESRD): If you re under 65 and disabed and you or your famiy member is sti working, your pan pays first if the empoyer has 100 or more empoyees or at east one empoyer in a mutipe empoyer pan has more than 100 empoyees. If you re over 65 and you or your spouse is sti working, the pan pays first if the empoyer has 20 or more empoyees or at east one empoyer in a mutipe empoyer pan has more than 20 empoyees. If you have Medicare because of ESRD, your group heath pan wi pay first for the first 30 months after you become eigibe for Medicare. These types of coverage usuay pay first for services reated to each type: No-faut insurance (incuding automobie insurance) Liabiity (incuding automobie insurance) Back ung benefits Workers compensation Medicaid and TRICARE never pay first for Medicare-covered services. They ony pay after Medicare, empoyer group heath pans, and/or Medigap have paid. If you have other insurance, te your doctor, hospita, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, ca Customer Service (phone numbers are printed on the back cover

24 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 1: Getting started as a member 19 of this booket). You may need to give your pan member ID number to your other insurers (once you have confirmed their identity) so your bis are paid correcty and on time.

25 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 20 Chapter 2. Important phone numbers and resources SECTION 1 WeCare Simpe (PDP) contacts (how to contact us, incuding how to reach Customer Service at the pan) SECTION 2 Medicare (how to get hep and information directy from the Federa Medicare program) SECTION 3 State Heath Insurance Assistance Program (free hep, information, and answers to your questions about Medicare) SECTION 4 Quaity Improvement Organization (paid by Medicare to check on the quaity of care for peope with Medicare) SECTION 5 Socia Security SECTION 6 Medicaid (a joint Federa and state program that heps with medica costs for some peope with imited income and resources) SECTION 7 Information about programs to hep peope pay for their prescription drugs SECTION 8 How to contact the Rairoad Retirement Board SECTION 9 Do you have group insurance or other heath insurance from an empoyer?... 36

26 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 21 SECTION 1 WeCare Simpe (PDP) contacts (how to contact us, incuding how to reach Customer Service at the pan) How to contact our pan s Customer Service For assistance with caims, biing or member card questions, pease ca or write to WeCare Simpe (PDP) Customer Service. We wi be happy to hep you. Method Customer Service - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. Customer Service aso has free anguage interpreter services avaiabe for non-engish speakers. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WEBSITE WeCare Prescription Insurance, Inc. P.O. Box 31370, Tampa, FL

27 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 22 How to contact us when you are asking for a coverage decision about your Part D prescription drugs A coverage decision is a decision we make about your benefits and coverage or about the amount we wi pay for your Part D prescription drugs. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 7 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). You may ca us if you have questions about our coverage decision process. Method Coverage Decisions for Part D Prescription Drugs - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WEBSITE WeCare Coverage Determinations Department Pharmacy P.O. Box 31577, Tampa, FL Overnight Address for Expedited Decisions: WeCare Prescription Insurance, Inc., Attn: Part D Coverage Determinations, 8735 Henderson Rd, Ren. 4, Tampa, FL

28 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 23 How to contact us when you are making an appea about your Part D prescription drugs An appea is a forma way of asking us to review and change a coverage decision we have made. For more information on making an appea about your Part D prescription drugs, see Chapter 7 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Appeas for Part D Prescription Drugs - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WEBSITE WeCare Prescription Insurance, Inc. Attn: Part D Appeas, P.O. Box 31383, Tampa, FL Overnight Address for Expedited Appea Requests: WeCare Prescription Insurance, Inc. Attn: Part D Appeas, 8735 Henderson Rd, Ren. 4, Tampa, FL

29 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 24 How to contact us when you are making a compaint about your Part D prescription drugs You can make a compaint about us or one of our network pharmacies, incuding a compaint about the quaity of your care. This type of compaint does not invove coverage or payment disputes. (If your probem is about the pan s coverage or payment, you shoud ook at the section above about making an appea.) For more information on making a compaint about your Part D prescription drugs, see Chapter 7 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Compaints about Part D prescription drugs - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE MEDICARE WEBSITE WeCare Heath Pans Grievance Department P.O. Box 31384, Tampa, FL You can submit a compaint about our pan directy to Medicare. To submit an onine compaint to Medicare go to

30 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 25 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 incudes determining requests to pay for our share of the costs of a drug that you have received. For more information on situations in which you may need to ask the pan for reimbursement or to pay a bi you have received from a provider, see Chapter 5 (Asking us to pay our share of the costs for covered drugs). Pease note: If you send us a payment request and we deny any part of your request, you can appea our decision. See Chapter 7 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)) for more information. Method Payment Requests - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. WRITE WEBSITE WeCare Reimbursement Department Pharmacy P.O. Box 31577, Tampa, FL

31 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 26 SECTION 2 Medicare (how to get hep and information directy from the Federa Medicare program) Medicare is the Federa heath insurance program for peope 65 years of age or oder, some peope under age 65 with disabiities, and peope with End-Stage Rena Disease (permanent kidney faiure requiring diaysis or a kidney transpant). The Federa agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes caed CMS ). This agency contracts with Medicare Prescription Drug Pans, incuding us. Method Medicare - Contact Information CALL MEDICARE, or Cas to this number are free. 24 hours a day, 7 days a week. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. WEBSITE This is the officia government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It aso has information about hospitas, nursing homes, physicians, home heath agencies, and diaysis faciities. It incudes bookets you can print directy from your computer. You can aso find Medicare contacts in your state. The Medicare website aso has detaied information about your Medicare eigibiity and enroment options with the foowing toos: Medicare Eigibiity Too: Provides Medicare eigibiity status information.

32 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 27 Method WEBSITE (continued) Medicare - Contact Information Medicare Pan Finder: Provides personaized information about avaiabe Medicare prescription drug pans, Medicare heath pans, and Medigap (Medicare Suppement Insurance) poicies in your area. These toos provide an estimate of what your out-of-pocket costs might be in different Medicare pans. You can aso use the website to te Medicare about any compaints you have about our pan: Te Medicare about your compaint: You may submit a compaint about our pan directy to Medicare. To submit a compaint to Medicare, go to Medicare takes your compaints seriousy and wi use this information to hep improve the quaity of the Medicare program. If you don t have a computer, your oca ibrary or senior center may be abe to hep you visit this website using its computer. Or, you can ca Medicare and te them what information you are ooking for. They wi find the information on the website, print it out, and send it to you. (You can ca Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca )

33 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 28 SECTION 3 State Heath Insurance Assistance Program (free hep, information, and answers to your questions about Medicare) The State Heath Insurance Assistance Program (SHIP) is a government program with trained counseors in every state. You can find the name, phone number and address of the SHIP for your state in the appendix at the back of this booket. SHIPs are independent (not connected with any insurance company or heath pan). It is a state program that gets money from the Federa government to give free oca heath insurance counseing to peope with Medicare. SHIP counseors can hep you with your Medicare questions or probems. They can hep you understand your Medicare rights, hep you make compaints about your medica care or treatment, and hep you straighten out probems with your Medicare bis. SHIP counseors can aso hep you understand your Medicare pan choices and answer questions about switching pans. SECTION 4 Quaity Improvement Organization (paid by Medicare to check on the quaity of care for peope with Medicare) There is a Quaity Improvement Organization for each state. You can find the name, address and phone number for the Quaity Improvement Organization in your state in the appendix at the back of this booket. Each Quaity Improvement Organization has a group of doctors and other heath care professionas who are paid by the Federa government. These organizations are paid by Medicare to check on and hep improve the quaity of care for peope with Medicare. Quaity Improvement Organizations are independent organizations. Quaity Improvement Organizations are not connected with our pan. You shoud contact the Quaity Improvement Organization in your state if you have a compaint about the quaity of care you have received. For exampe, you can contact your Quaity Improvement Organization if you were given the wrong medication or if you were given medications that interact in a negative way.