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.

34 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 29 SECTION 5 Socia Security Socia Security is responsibe for determining eigibiity and handing enroment for Medicare. U.S. citizens who are 65 or oder, or who have a disabiity or End-Stage Rena Disease and meet certain conditions, are eigibe for Medicare. If you are aready getting Socia Security checks, enroment into Medicare is automatic. If you are not getting Socia Security checks, you have to enro in Medicare. Socia Security handes the enroment process for Medicare. To appy for Medicare, you can ca Socia Security or visit your oca Socia Security office. Socia Security is aso responsibe 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 etter from Socia Security teing you that you have to pay the extra amount and have questions about the amount or if your income went down because of a ife-changing event, you can ca Socia Security to ask for a reconsideration. If you move or change your maiing address, it is important that you contact Socia Security to et them know. Method CALL Socia Security - Contact Information Cas to this number are free. TTY WEBSITE Avaiabe 7:00 am to 7:00 pm, Monday through Friday. You can use Socia Security s automated teephone services to get recorded information and conduct some business 24 hours a day. This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Avaiabe 7:00 am ET to 7:00 pm, Monday through Friday.

35 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 30 SECTION 6 Medicaid (a joint Federa and state program that heps with medica costs for some peope with imited income and resources) Medicaid is a joint Federa and state government program that heps with medica costs for certain peope with imited incomes and resources. Some peope with Medicare are aso eigibe for Medicaid. In addition, there are programs offered through Medicaid that hep peope with Medicare pay their Medicare costs, such as their Medicare premiums. These Medicare Savings Programs hep peope with imited income and resources save money each year: Quaified Medicare Beneficiary (QMB): Heps pay Medicare Part A and Part B premiums, and other cost-sharing (ike deductibes, coinsurance, and co-payments). (Some peope with QMB are aso eigibe for fu Medicaid benefits (QMB+).) Specified Low-Income Medicare Beneficiary (SLMB): Heps pay Part B premiums. (Some peope with SLMB are aso eigibe for fu Medicaid benefits (SLMB+).) Quaified Individua (QI): Heps pay Part B premiums. Quaified Disabed & Working Individuas (QDWI): Heps pay Part A premiums. To find out more about Medicaid and its programs, contact the Medicaid agency for your state. You can find the name, phone number and address isted in the appendix at the back of this booket. SECTION 7 Information about programs to hep peope pay for their prescription drugs Medicare s Extra Hep Program Medicare provides Extra Hep to pay prescription drug costs for peope who have imited income and resources. Resources incude your savings and stocks, but not your home or car. If you quaify, you get hep paying for any Medicare drug pan s monthy premium, yeary deductibe and prescription co-payments or coinsurance. This "Extra Hep" aso counts toward your out-of-pocket costs.

36 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 31 Peope with imited income and resources may quaify for "Extra Hep". Some peope automaticay quaify for "Extra Hep" and don t need to appy. Medicare mais a etter to peope who automaticay quaify for "Extra Hep". You may be abe to get "Extra Hep" to pay for your prescription drug premiums and costs. To see if you quaify for getting "Extra Hep", ca: MEDICARE ( ). TTY users shoud ca , 24 hours a day, 7 days a week; The Socia Security Office at , between 7 a.m. to 7 p.m., Monday through Friday. TTY users shoud ca (appications); or Your State Medicaid Office (appications). (See the appendix at the back of this booket for contact information.) If you beieve you have quaified for "Extra Hep" and you beieve that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our pan has estabished a process that aows you to either request assistance in obtaining evidence of your proper co-payment eve, or, if you aready have the evidence, to provide this evidence to us. Your Best Avaiabe Evidence (BAE) is a document that shows you quaify for "Extra Hep" with your prescription drug costs. Documents you can use as Best Avaiabe Evidence are isted beow. Pease fax or mai a copy of one or more of these documents to WeCare. Medicaid card that incudes name and eigibiity date during a month after June of the previous caendar year Copy of a state document that confirms active Medicaid status during a month after June of the previous caendar year Socia Security Administration (SSA) award etter to determine eigibiity for fu or partia subsidy A state document or eectronic enroment fie that confirms active Medicaid status during a month after June of the previous caendar year Screen print from your state s Medicaid systems showing Medicaid status during a month after June of the previous caendar year Other documentation provided by your state showing Medicaid status during a month after June of the previous caendar year

37 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 32 State document showing Medicaid payment for a fu caendar month at an institution Screen print from your state s Medicaid systems that shows Medicaid paid for a stay of at east a fu caendar month at an institution A remittance from the faciity showing Medicaid payment for a fu caendar month during a month after June of the previous caendar year An Appication Fied by Deemed Eigibe confirming "...automaticay eigibe for Extra Hep..." A State-issued Notice of Action, Notice of Determination, or Notice of Enroment that incudes the beneficiary s name and HCBS (Home and Community Based Services) eigibiity date during a month after June of the previous caendar year A State-approved HCBS Service Pan that incudes the beneficiary s name and effective date beginning during a month after June of the previous caendar year A State-issued prior authorization approva etter for HCBS that incudes the beneficiary s name and effective date beginning during a month after June of the previous caendar year Other documentation provided by the State showing HCBS eigibiity status during a month after June of the previous caendar year; or, A state-issued document, such as a remittance advice, confirming payment for HCBS, incuding the beneficiary s name and the dates of HCBS. Urgent BAE Fax to: (Attn: BAE) OR Mai to: WeCare Heath Pans Attn: LISOVR P.O. Box Tampa, FL Non Urgent BAE: Fax to: OR Mai to: WeCare Heath Pans Attn: LISOVR P.O. Box Tampa, FL

38 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 33 You can aso get more information about how to submit this evidence on our website at If you have difficuty obtaining any document isted above, contact Customer Service. When we receive the evidence showing your co-payment eve, we wi update our system so that you can pay the correct co-payment when you get your next prescription at the pharmacy. If you overpay your co-payment, we wi reimburse you. Either we wi forward a check to you in the amount of your overpayment or we wi offset future co-payments. If the pharmacy hasn t coected a co-payment from you and is carrying your co-payment as a debt owed by you, we may make the payment directy to the pharmacy. If a state paid on your behaf, we may make payment directy to the state. Pease contact Customer Service if you have questions (phone numbers are printed on the back cover of this booket). Medicare Coverage Gap Discount Program The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enroees who have reached the coverage gap and are not aready receiving Extra Hep. A 50% discount on the negotiated price (excuding the dispensing fee and vaccine administration fee, if any) is avaiabe for those brand name drugs from manufacturers that have agreed to pay the discount. The pan pays an additiona 5% and you pay the remaining 45% for your brand drugs. If you reach the coverage gap, we wi automaticay appy the discount when your pharmacy bis you for your prescription and your Part D Expanation of Benefits (EOB) wi show any discount provided. 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 moves you through the coverage gap. The amount paid by the pan (5%) does not count toward your out-of-pocket costs. You aso receive some coverage for generic drugs. If you reach the coverage gap, the pan pays 35% of the price for generic drugs and you pay the remaining 65% of the price. For generic drugs, the amount paid by the pan (35%) does not count toward your out-of-pocket costs. Ony the amount you pay counts and moves you through the coverage gap. Aso, the dispensing fee is incuded as part of the cost of the drug. If you have any questions about the avaiabiity of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in genera, pease contact Customer Service (phone numbers are printed on the back cover of this booket).

39 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 34 What if you have coverage from a State Pharmaceutica Assistance Program (SPAP)? If you are enroed in a State Pharmaceutica Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than "Extra Hep"), you sti get the 50% discount on covered brand name drugs. Aso, the pan pays 5% of the costs of brand drugs in the coverage gap. The 50% discount and the 5% paid by the pan is appied 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) heps ADAP-eigibe individuas iving with HIV/AIDS have access to ife-saving HIV medications. Medicare Part D prescription drugs that are aso covered by ADAP quaify for prescription cost-sharing assistance. Note: To be eigibe for the ADAP operating in your State, individuas must meet certain criteria, incuding proof of State residence and HIV status, ow income as defined by the State, and uninsured/under-insured status. If you are currenty enroed in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formuary. In order to be sure you continue receiving this assistance, pease notify your oca ADAP enroment worker of any changes in your Medicare Part D pan name or poicy number. For information on eigibiity criteria, covered drugs, or how to enro in the program, contact your oca ADAP. You can find the name, phone number and address of your state's AIDS Drug Assistance Program (ADAP) isted in the appendix at the back of this booket, if avaiabe in your region. What if you get "Extra Hep" from Medicare to hep pay your prescription drug costs? Can you get the discounts? No. If you get "Extra Hep", you aready get coverage for your prescription drug costs during the coverage gap. What if you don t get a discount, and you think you shoud have? If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you shoud review your next Part D

40 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 35 Expanation of Benefits (Part D EOB) notice. If the discount doesn t appear on your Part D Expanation of Benefits, you shoud contact us to make sure that your prescription records are correct and up-to-date. If we don t agree that you are owed a discount, you can appea. You can get hep fiing an appea from your State Heath Insurance Assistance Program (SHIP) (teephone numbers are in the appendix at the back of this booket) or by caing MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca State Pharmaceutica Assistance Programs Many states have State Pharmaceutica Assistance Programs that hep some peope pay for prescription drugs based on financia need, age, or medica condition. Each state has different rues to provide drug coverage to its members. These programs provide imited income and medicay needy seniors and individuas with disabiities financia hep for prescription drugs. You can find the name, phone number and address of your state s State Pharmaceutica Assistance Program isted in the appendix at the back of this booket, if avaiabe in your region. SECTION 8 How to contact the Rairoad Retirement Board The Rairoad Retirement Board is an independent Federa agency that administers comprehensive benefit programs for the nation s rairoad workers and their famiies. If you have questions regarding your benefits from the Rairoad Retirement Board, contact the agency. If you receive your Medicare through the Rairoad Retirement Board, it is important that you et them know if you move or change your maiing address.

41 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 2: Important phone numbers and resources 36 Method CALL Rairoad Retirement Board - Contact Information Cas to this number are free. TTY Avaiabe 9:00 am to 3:30 pm, Monday through Friday If you have a touch-tone teephone, recorded information and automated services are avaiabe 24 hours a day, incuding weekends and hoidays. This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. WEBSITE Cas to this number are not free. SECTION 9 Do you have group insurance or other heath insurance from an empoyer? If you (or your spouse) get benefits from your (or your spouse s) empoyer or retiree group as part of this pan, you may ca the empoyer/union benefits administrator or Customer Service if you have any questions. You can ask about your (or your spouse s) empoyer or retiree heath or drug benefits, premiums, or enroment period. (Phone numbers for Customer Service are printed on the back cover of this booket.) You may aso ca MEDICARE ( ; TTY: ) with questions reated to your Medicare coverage under this pan. If you have other prescription drug coverage through your (or your spouse s) empoyer or retiree group, pease contact that group s benefits administrator. The benefits administrator can hep you determine how your current prescription drug coverage wi work with our pan.

42 2015 Evidence of Coverage for WeCare Simpe (PDP) 37 Chapter 3: Using the pan's coverage for your Part D prescription drugs Chapter3. Using the pan's coverage for your Part D prescription drugs SECTION 1 Introduction...39 Section 1.1 This chapter describes your coverage for Part D drugs...39 Section 1.2 Basic rues for the pan s Part D drug coverage...40 SECTION 2 Fi your prescription at a network pharmacy or through the pan s mai service...40 Section 2.1 To have your prescription covered, use a network pharmacy...40 Section 2.2 Finding network pharmacies...41 Section 2.3 Using the pan s mai services...42 Section 2.4 How can you get a ong-term suppy of drugs?...44 Section 2.5 When can you use a pharmacy that is not in the pan s network?..44 SECTION 3 Your drugs need to be on the pan s Drug List...46 Section 3.1 The Drug List tes which Part D drugs are covered...46 Section 3.2 There are five cost-sharing tiers for drugs on the Drug List...47 Section 3.3 How can you find out if a specific drug is on the Drug List?...48 SECTION 4 There are restrictions on coverage for some drugs...48 Section 4.1 Why do some drugs have restrictions?...48 Section 4.2 What kinds of restrictions?...49 Section 4.3 Do any of these restrictions appy to your drugs?...50 SECTION 5 What if one of your drugs is not covered in the way you d ike it to be covered?...50 Section 5.1 There are things you can do if your drug is not covered in the way you d ike it to be covered...50 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?...51 Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high?...54 SECTION 6 What if your coverage changes for one of your drugs?...55

43 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 38 Section 6.1 The Drug List can change during the year...55 Section 6.2 What happens if coverage changes for a drug you are taking?...55 SECTION 7 What types of drugs are not covered by the pan?...57 Section 7.1 Types of drugs we do not cover...57 SECTION 8 Show your pan membership card when you fi a prescription..58 Section 8.1 Show your membership card...58 Section 8.2 What if you don t have your membership card with you?...58 SECTION 9 Part D drug coverage in specia situations...59 Section 9.1 What if you re in a hospita or a skied nursing faciity for a stay that is covered by Origina Medicare?...59 Section 9.2 What if you re a resident in a ong-term care (LTC) faciity?...59 Section 9.3 What if you are taking drugs covered by Origina Medicare?...60 Section 9.4 What if you have a Medigap (Medicare Suppement Insurance) poicy with prescription drug coverage?...61 Section 9.5 What if you re aso getting drug coverage from an empoyer or retiree group pan?...61 SECTION 10 Programs on drug safety and managing medications...62 Section 10.1 Programs to hep members use drugs safey...62 Section 10.2 Medication Therapy Management (MTM) program to hep members manage their medications...62

44 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 39? Did you know there are programs to hep peope pay for their drugs? There are programs to hep peope with imited resources pay for their drugs. These incude Extra Hep and State Pharmaceutica Assistance Programs. For more information, see Chapter 2, Section 7. Are you currenty getting hep to pay for your drugs? If you are in a program that heps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs 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 ), that 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.) SECTION 1 Introduction Section 1.1 This chapter describes your coverage for Part D drugs This chapter expains rues for using your coverage for Part D drugs. The next chapter tes what you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs). In addition to your coverage for Part D drugs through our pan, Origina Medicare (Medicare Part A and Part B) aso covers some drugs: Medicare Part A covers drugs you are given during Medicare-covered stays in the hospita or in a skied nursing faciity. Medicare Part B aso provides benefits for some drugs. Part B drugs incude certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a diaysis faciity. The two exampes of drugs described above are covered by Origina Medicare. (To find out more about this coverage, see your Medicare & You Handbook.) Your Part D prescription drugs are covered under our pan.

45 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 40 Section 1.2 Basic rues for the pan s Part D drug coverage The pan wi generay cover your drugs as ong as you foow these basic rues: You must have a provider (a doctor or other prescriber) write your prescription. Effective June 1, 2015, your prescriber must either accept Medicare or fie documentation with CMS showing that he or she is quaified to write prescriptions. You shoud ask your prescribers the next time you ca or visit if they meet this condition. You generay must use a network pharmacy to fi your prescription. (See Section 2, Fi your prescriptions at a network pharmacy or through the pan s mai service.) Your drug must be on the pan s List of Covered Drugs (Formuary) (we ca it the Drug List for short). (See Section 3, Your drugs need to be on the pan s Drug List. ) Your drug must be used for a medicay accepted indication. A medicay 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 medicay accepted indication.) SECTION 2 Fi your prescription at a network pharmacy or through the pan s mai service Section 2.1 To have your prescription covered, use a network pharmacy In most cases, your prescriptions are covered ony if they are fied at the pan s network pharmacies. (See Section 2.5 for information about when we woud cover prescriptions fied at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with the pan to provide your covered prescription drugs. The term covered drugs means a of the Part D prescription drugs that are covered on the pan s Drug List. Our network incudes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing. You may go to either type of network pharmacy to receive your covered prescription drugs. Your cost-sharing may be ess at pharmacies with preferred cost-sharing.

46 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 41 Section 2.2 Finding network pharmacies How do you find a network pharmacy in your area? To find a network pharmacy, you can ook in your Pharmacy Directory, visit our website ( or ca Customer Service (phone numbers are printed on the back cover of this booket). Choose whatever is easiest for you. You may go to any of our network pharmacies. However, your costs may be even ess for your covered drugs if you use a network pharmacy that offers preferred cost-sharing rather than a network pharmacy that offers standard cost-sharing. The Pharmacy Directory wi te you which of the network pharmacies offer preferred cost-sharing. If you switch from one network pharmacy to another, and you need a refi of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy. What if the pharmacy you have been using eaves the network? If the pharmacy you have been using eaves the pan s network, you wi have to find a new pharmacy that is in the network. Or if the pharmacy you have been using stays within the network but is no onger offering preferred cost-sharing, you may want to switch to a different pharmacy. To find another network pharmacy in your area, you can get hep from Customer Service (phone numbers are printed on the back cover of this booket) or use the Pharmacy Directory. You can aso find information on our website at What if you need a speciaized pharmacy? Sometimes prescriptions must be fied at a speciaized pharmacy. Speciaized pharmacies incude: Pharmacies that suppy drugs for home infusion therapy. Pharmacies that suppy drugs for residents of a ong-term care (LTC) faciity. Usuay, a ong-term care faciity (such as a nursing home) has its own pharmacy. Residents may get prescription drugs through the faciity s pharmacy as ong as it is part of our network. If your ong-term care pharmacy is not in our network, pease contact Customer Service. Pharmacies that serve the Indian Heath Service / Triba / Urban Indian Heath Program (not avaiabe in Puerto Rico). Except in emergencies, ony Native Americans or Aaska Natives have access to these pharmacies in our network.

47 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 42 Pharmacies that dispense drugs that are restricted by the FDA to certain ocations or that require specia handing, provider coordination, or education on their use. (Note: This scenario shoud happen rarey.) To ocate a speciaized pharmacy, ook in your Pharmacy Directory or ca Customer Service (phone numbers are printed on the back cover of this booket). Section 2.3 Using the pan s mai services For certain kinds of drugs, you can use the pan s network mai services. Generay, the drugs provided through mai service are drugs that you take on a reguar basis, for a chronic or ong-term medica condition. The drugs avaiabe through our pan s mai service are marked as mai service drugs in our Drug List. Our pan s mai service aows you to order up to a 90-day suppy. To get order forms and information about fiing your prescriptions by mai: 1. Ca our mai service Customer Service at (TTY ) 24 hours a day, 7 days a week for assistance. Or, og on to 2. Compete the Mai Service Enroment Form. 3. New prescriptions must be maied with the enroment form. Providers may fax new prescriptions to Mai Service at Most orders are shipped by the U.S. Posta Service. Controed substances may require an adut signature upon receipt. Packaging does not show any indication that medications are encosed. If you prefer different shipping arrangements for privacy or other reasons, pease contact our mai service Customer Service at the phone number isted above. 5. Pease aow up to business days for deivery. The business days begins when we receive your prescription and order form. 6. Incude payment or payment information, if appicabe, to avoid any deays. 7. We accept checks, credit cards and debit cards. Pease do not send cash. 8. A non-member initiated prescriptions wi require the pharmacy to contact you for consent.

48 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 43 If you use a mai service pharmacy not in the pan s network, your prescription wi not be covered. Usuay a mai service pharmacy order wi get to you in no more than business days. However, sometimes your mai service prescriptions may be deayed. For ong-term medications that you need right away, ask your doctor for two prescriptions: one for a 30-day suppy to fi at a participating retai pharmacy, and one for a ong-term suppy to fi through the mai. If you have any probem with getting your 30-day suppy fied at a participating retai pharmacy when your mai service prescription is deayed, pease have your retai pharmacy ca our Provider Service Center at (TTY ), 24 hours a day, 7 days a week for assistance. Members can ca mai service Customer Service at (TTY ), 24 hours a day, 7 days a week. Or, og on to New prescriptions the pharmacy receives directy from your doctor s office. After the pharmacy receives a prescription from a heath care provider, it wi contact you to see if you want the medication fied immediatey or at a ater time. This wi give you an opportunity to make sure that the pharmacy is deivering the correct drug (incuding strength, amount, and form) and, if necessary, aow you to cance or deay the order before you are bied and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to et them know what to do with the new prescription and to prevent any deays in shipping. Refis on mai service prescriptions. For refis of your drugs, you have the option to sign up for an automatic refi program. Under this program we wi start to process your next refi automaticay when our records show you shoud be cose to running out of your drug. The pharmacy wi contact you prior to shipping each refi to make sure you are in need of more medication, and you can cance schedued refis if you have enough of your medication or if your medication has changed. If you choose not to use our auto refi program, pease contact your pharmacy at east 10 days before you think the drugs you have on hand wi run out to make sure your next order is shipped to you in time. To opt out of our program that automaticay prepares mai service refis, pease contact our mai service Customer Service at (TTY ).

49 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 44 So the pharmacy can reach you to confirm your order before shipping, pease make sure to et the pharmacy know the best ways to contact you. Contact our mai service Customer Service at (TTY ). Section 2.4 How can you get a ong-term suppy of drugs? When you get a ong-term suppy of drugs, your cost-sharing may be ower. The pan offers two ways to get a ong-term suppy of maintenance drugs on our pan s Drug List. (Maintenance drugs are drugs that you take on a reguar basis, for a chronic or ong-term medica condition.) 1. Some retai pharmacies in our network aow you to get a ong-term suppy of maintenance drugs. Your Pharmacy Directory tes you which pharmacies in our network can give you a ong-term suppy of maintenance drugs. You can aso ca Customer Service for more information (phone numbers are printed on the back cover of this booket). 2. For certain kinds of drugs, you can use the pan s network mai services. The drugs avaiabe through our pan s mai service are marked as mai service drugs in our Drug List. Our pan s mai service aows you to order up to a 90-day suppy. See Section 2.3 for more information about using our mai services. Section 2.5 When can you use a pharmacy that is not in the pan s network? Your prescription may be covered in certain situations We have network pharmacies outside of our service area where you can get your prescriptions fied as a member of our pan. Generay, we cover drugs fied at an out-of-network pharmacy ony when you are not abe to use a network pharmacy. Here are the circumstances when we woud cover prescriptions fied at an out-of-network pharmacy: Trave: Getting coverage when you trave or are away from the pan s service area If you take a prescription drug on a reguar basis and you are going on a trip, be sure to check your suppy of the drug before you eave. When possibe, take aong a the medication you wi need. You may be abe to order your prescription drugs ahead of time through our mai service pharmacy service.

50 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 45 If you are traveing within the United States and territories and become i, ose, or run out of your prescription drugs, we wi cover prescriptions that are fied at an out-of-network pharmacy. In this situation, you wi have to pay the fu cost (rather than paying just your co-payment or coinsurance) when you fi your prescription. You can ask us to reimburse you for our share of the cost by submitting a reimbursement form. If you go to an out-of-network pharmacy, you may be responsibe for paying the difference between what we woud pay for a prescription fied at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To earn how to submit a reimbursement caim, pease refer to Chapter 5, Section 2.1, How and where to send us your request for payment. You can aso ca Customer Service to find out if there is a network pharmacy in the area where you are traveing. We cannot pay for any prescriptions that are fied by pharmacies outside of the United States and territories, even for a medica emergency. Medica Emergency: What if I need a prescription because of a medica emergency or because I needed urgent care? We wi cover prescriptions that are fied at an out-of-network pharmacy if the prescriptions are reated to care for a medica emergency or urgent care. In this situation, you wi have to pay the fu cost (rather than paying just your co-payment or coinsurance) when you fi your prescription. You can ask us to reimburse you for our share of the cost by submitting a reimbursement form. If you go to an out-of-network pharmacy, you may be responsibe for paying the difference between what we woud pay for a prescription fied at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To earn how to submit a reimbursement caim, pease refer to Chapter 5, Section 2.1, How and where to send us your request for payment. Additiona Situations: Other times you can get your prescription covered if you go to an out-of-network pharmacy We wi cover your prescription at an out-of-network pharmacy if at east one of the foowing appies: If you are unabe to obtain a covered drug in a timey manner within our service area because there is no network pharmacy, within a reasonabe driving distance, that provides 24-hour service.

51 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 46 If you are trying to fi a prescription drug that is not reguary stocked at an accessibe network retai or mai service pharmacy (incuding high-cost and unique drugs). If you are getting a vaccine that is medicay necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor s office. For a of the above-isted situations, you may receive up to a 30-day suppy of prescription drugs. In addition, you wi ikey have to pay the out-of-network pharmacy s charge for the drug and submit documentation to receive reimbursement from WeCare. Pease be sure to incude an expanation of the situation concerning why you used a pharmacy outside of our network. This wi hep with the processing of your reimbursement request. In these situations, pease check first with Customer Service to see if there is a network pharmacy nearby. (Phone numbers for Customer Service are printed on the back cover of this booket.) How do you ask for reimbursement from the pan? If you must use an out-of-network pharmacy, you wi generay have to pay the fu cost (rather than your norma share of the cost) when you fi your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 expains how to ask the pan to pay you back.) SECTION 3 Your drugs need to be on the pan s Drug List Section 3.1 The Drug List tes which Part D drugs are covered The pan has a List of Covered Drugs (Formuary). In this Evidence of Coverage, we ca it the Drug List for short. The drugs on this ist are seected by the pan with the hep of a team of doctors and pharmacists. The ist must meet requirements set by Medicare. Medicare has approved the pan s Drug List. The drugs on the Drug List are ony those covered under Medicare Part D (earier in this chapter, Section 1.1 expains about Part D drugs).

52 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 47 We wi generay cover a drug on the pan s Drug List as ong as you foow the other coverage rues expained in this chapter and use of the drug is a medicay accepted indication. A medicay accepted indication is a use of the drug that is either: approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) -- or -- supported by certain reference books. (These reference books are the American Hospita Formuary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor.) The Drug List incudes both brand name and generic drugs A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generay, it works just as we as the brand name drug and usuay costs ess. There are generic drug substitutes avaiabe for many brand name drugs. What is not on the Drug List? The pan does not cover a prescription drugs. In some cases, the aw does not aow any Medicare pan 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 incude a particuar drug on our Drug List. Section 3.2 There are five cost-sharing tiers for drugs on the Drug List Every drug on the pan s Drug List is in one of five cost-sharing tiers. In genera, the higher the cost-sharing tier, the higher your cost for the drug: Cost-Sharing Tier 1 (Preferred Generic Drugs) incudes preferred generic drugs. This is the owest cost-sharing tier. Cost-Sharing Tier 2 (Non-Preferred Generic Drugs) incudes non-preferred generic drugs. Cost-Sharing Tier 3 (Preferred Brand Drugs) incudes generic & preferred brand drugs. Cost-Sharing Tier 4 (Non-Preferred Brand Drugs) incudes generic & non-preferred brand drugs.

53 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 48 Cost-Sharing Tier 5 (Speciaty Tier Drugs) incudes generic & brand drugs. This is the highest cost-sharing tier. To find out which cost-sharing tier your drug is in, ook it up in the pan 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 three ways to find out: 1. Check the most recent Drug List we sent you in the mai. (Pease note: The Drug List we send 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.) 2. Visit the pan s website ( The Drug List on the website is aways the most current. 3. Ca Customer Service to find out if a particuar drug is on the pan s Drug List or to ask for a copy of the ist. (Phone numbers for Customer Service are printed on the back cover of this booket.) SECTION 4 There are restrictions on coverage for some drugs Section 4.1 Why do some drugs have restrictions? For certain prescription drugs, specia rues restrict how and when the pan covers them. A team of doctors and pharmacists deveoped these rues to hep our members use drugs in the most effective ways. These specia rues aso hep contro overa drug costs, which keeps your drug coverage more affordabe. In genera, our rues encourage you to get a drug that works for your medica condition and is safe and effective. Whenever a safe, ower-cost drug wi work just as we medicay as a higher-cost drug, the pan s rues are designed to encourage you and your provider to use that ower-cost option. We aso need to compy with Medicare s rues and reguations for drug coverage and cost-sharing.

54 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 49 If there is a restriction for your drug, it usuay means that you or your provider wi have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you wi 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, Section 5.2 for information about asking for exceptions.) Pease note that sometimes a drug may appear more than once in our drug ist. This is because different restrictions or cost-sharing may appy based on factors such as the strength, amount, or form of the drug prescribed by your heath care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tabet versus iquid). Section 4.2 What kinds of restrictions? Our pan uses different types of restrictions to hep our members use drugs in the most effective ways. The sections beow te you more about the types of restrictions we use for certain drugs. Restricting brand name drugs when a generic version is avaiabe Generay, a generic drug works the same as a brand name drug and usuay costs ess. In most cases, when a generic version of a brand name drug is avaiabe, our network pharmacies wi provide you the generic version. We usuay wi not cover the brand name drug when a generic version is avaiabe. However, if your provider has tod us the medica reason that neither the generic drug nor other covered drugs that treat the same condition wi work for you, then we wi cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.) Getting pan approva in advance For certain drugs, you or your provider need to get approva from the pan before we wi agree to cover the drug for you. This is caed prior authorization. Sometimes the requirement for getting approva in advance heps guide appropriate use of certain drugs. If you do not get this approva, your drug might not be covered by the pan. Trying a different drug first This requirement encourages you to try ess costy but just as effective drugs before the pan covers another drug. For exampe, if Drug A and Drug B treat the same medica condition, the pan may require you to try Drug A first. If Drug A does not

55 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 50 work for you, the pan wi then cover Drug B. This requirement to try a different drug first is caed step therapy. Quantity imits For certain drugs, we imit the amount of the drug that you can have. For exampe, the pan might imit how many refis you can get, or how much of a drug you can get each time you fi your prescription. For exampe, if it is normay considered safe to take ony one pi per day for a certain drug, we may imit coverage for your prescription to no more than one pi per day. Section 4.3 Do any of these restrictions appy to your drugs? The pan s Drug List incudes information about the restrictions described above. To find out if any of these restrictions appy to a drug you take or want to take, check the Drug List. For the most up-to-date information, ca Customer Service (phone numbers are printed on the back cover of this booket) or check our website ( If there is a restriction for your drug, it usuay means that you or your provider wi have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you shoud contact Customer Service to earn what you or your provider woud need to do to get coverage for the drug. If you want us to waive the restriction for you, you wi 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, Section 5.2 for information about asking for exceptions.) SECTION 5 What if one of your drugs is not covered in the way you d ike it to be covered? Section 5.1 There are things you can do if your drug is not covered in the way you d ike it to be covered Suppose there is a prescription drug you are currenty taking, or one that you and your provider think you shoud be taking. We hope that your drug coverage wi work we for you, but it s possibe that you might have a probem. For exampe: What if the drug you want to take is not covered by the pan? For exampe, the drug might not be covered at a. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered.

56 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 51 What if the drug is covered, but there are extra rues or restrictions on coverage for that drug? As expained in Section 4, some of the drugs covered by the pan have extra rues to restrict their use. For exampe, you might be required to try a different drug first, to see if it wi work, before the drug you want to take wi be covered for you. Or there might be imits on what amount of the drug (number of pis, etc.) is covered during a particuar time period. In some cases, you may want us to waive the restriction for you. For exampe, you might want us to cover a certain drug for you without having to try other drugs first. Or you may want us to cover more of a drug (number of pis, etc.) than we normay wi cover. What if the drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more expensive than you think it shoud be? The pan puts each covered drug into one of five different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. There are things you can do if your drug is not covered in the way that you d ike it to be covered. Your options depend on what type of probem you have: If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to earn what you can do. If your drug is in a cost-sharing tier that makes your cost more expensive than you think it shoud be, go to Section 5.3 to earn 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 things you can do: You may be abe to get a temporary suppy of the drug (ony members in certain situations can get a temporary suppy). This wi give you and your provider time to change to another drug or to fie a request to have the drug covered. You can change to another drug. You can request an exception and ask the pan to cover the drug or remove restrictions from the drug. You may be abe to get a temporary suppy

57 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 52 Under certain circumstances, the pan can offer a temporary suppy of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to tak with your provider about the change in coverage and figure out what to do. To be eigibe for a temporary suppy, you must meet the two requirements beow: 1. The change to your drug coverage must be one of the foowing types of changes: The drug you have been taking is no onger on the pan s Drug List. -- or -- the drug you have been taking is now restricted in some way (Section 4 in this chapter tes about restrictions). 2. You must be in one of the situations described beow: For those members who were in the pan ast year and aren t in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 90 days of the caendar year. This temporary suppy wi be for a maximum of 30 days. If your prescription is written for fewer days, we wi aow mutipe fis to provide up to a maximum of a 30-day suppy of medication. The prescription must be fied at a network pharmacy. For those members who are new to the pan and aren t in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 90 days of your membership in the pan. This temporary suppy wi be for a maximum of 30 days. If your prescription is written for fewer days, we wi aow mutipe fis to provide up to a maximum of a 30-day suppy of medication. The prescription must be fied at a network pharmacy. For those members who were in the pan ast year and reside in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 98 days of the caendar year. The tota suppy wi be for a maximum of 98 days. If your prescription is written for fewer days, we wi aow mutipe fis to provide up to a maximum of a 98-day suppy of medication. (Pease note that the ong-term care pharmacy may provide the drug in smaer amounts at a time to prevent waste.)

58 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 53 For those members who are new to the pan and reside in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 98 days of your membership in the pan. The tota suppy wi be for a maximum of a 98-day suppy. If your prescription is written for fewer days, we wi aow mutipe fis to provide up to a maximum of a 98-day suppy of medication. (Pease note that the ong-term care pharmacy may provide the drug in smaer amounts at a time to prevent waste.) For those members who have been in the pan for more than 98 days and reside in a ong-term care (LTC) faciity and need a suppy right away: We wi cover one 31-day suppy, or ess if your prescription is written for fewer days. This is in addition to the above ong-term care transition suppy. For those current members who experience a eve of care change: There are times when a member may experience an unpanned eve of care change transition (such as being discharged or admitted to a ong-term care faciity, discharged or admitted to hospitas, nursing faciity ski eve changes, etc.). In these instances, we wi provide an emergency suppy of non-formuary medications (incuding Part D medications that are on the formuary, but require prior authorization or step therapy under our utiization management rues). This emergency suppy wi be for at east 3 days of medication, uness the prescription is written for fewer days. The emergency suppy is to ensure that members receive their medications whie an exception has been requested through the pan. To ask for a temporary suppy, ca Customer Service (phone numbers are printed on the back cover of this booket). During the time when you are getting a temporary suppy of a drug, you shoud tak with your provider to decide what to do when your temporary suppy runs out. You can either switch to a different drug covered by the pan or ask the pan to make an exception for you and cover your current drug. The sections beow te you more about these options. You can change to another drug Start by taking with your provider. Perhaps there is a different drug covered by the pan that might work just as we for you. You can ca Customer Service to ask for a ist of covered drugs that treat the same medica condition. This ist can hep your

59 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 54 provider find a covered drug that might work for you. (Phone numbers for Customer Service are printed on the back cover of this booket.) You can ask for an exception You and your provider can ask the pan to make an exception for you and cover the drug in the way you woud ike it to be covered. If your provider says that you have medica reasons that justify asking us for an exception, your provider can hep you request an exception to the rue. For exampe, you can ask the pan to cover a drug even though it is not on the pan s Drug List. Or you can ask the pan to make an exception and cover the drug without restrictions. If you are a current member and a drug you are taking wi be removed from the formuary or restricted in some way for next year, we wi aow you to request a formuary exception in advance for next year. We wi te you about any change in the coverage for your drug for next year. You can ask for an exception before next year and we wi give you an answer within 72 hours after we receive your request (or your prescriber s supporting statement). If we approve your request, we wi authorize the coverage before the change takes effect. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tes what to do. It expains the procedures and deadines that have been set by Medicare to make sure your request is handed prompty and fairy. Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? If your drug is in a cost-sharing tier you think is too high, here are things you can do: You can change to another drug If your drug is in a cost-sharing tier you think is too high, start by taking with your provider. Perhaps there is a different drug in a ower cost-sharing tier that might work just as we for you. You can ca Customer Service to ask for a ist of covered drugs that treat the same medica condition. This ist can hep your provider find a covered drug that might work for you. (Phone numbers for Customer Service are printed on the back cover of this booket.)

60 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 55 You can ask for an exception For drugs in Tier 2 (Non-Preferred Generic Drugs) and Tier 4 (Non-Preferred Brand Drugs), you and your provider can ask the pan to make an exception in the cost-sharing tier for the drug so that you pay ess for it. If your provider says that you have medica reasons that justify asking us for an exception, your provider can hep you request an exception to the rue. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tes what to do. It expains the procedures and deadines that have been set by Medicare to make sure your request is handed prompty and fairy. Drugs in some of our cost-sharing tiers are not eigibe for this type of exception. We do not ower the cost-sharing amount for drugs in Tier 1 (Preferred Generic Drugs), Tier 3 (Preferred Brand Drugs) or Tier 5 (Speciaty Tier Drugs). SECTION 6 Section 6.1 What if your coverage changes for one of your drugs? 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 pan might make many kinds of changes to the Drug List. For exampe, the pan might: Add or remove drugs from the Drug List. New drugs become avaiabe, incuding new generic drugs. Perhaps the government has given approva to a new use for an existing drug. Sometimes, a drug gets recaed and we decide not to cover it. Or we might remove a drug from the ist because it has been found to be ineffective. Move a drug to a higher or ower cost-sharing tier. Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 4 in this chapter). Repace a brand name drug with a generic drug. In amost a cases, we must get approva from Medicare for changes we make to the pan s Drug List. Section 6.2 What happens if coverage changes for a drug you are taking?

61 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 56 How wi you find out if your drug s coverage has been changed? If there is a change to coverage for a drug you are taking, the pan wi send you a notice to te you. Normay, we wi et you know at east 60 days ahead of time. Once in a whie, a drug is suddeny recaed because it s been found to be unsafe or for other reasons. If this happens, the pan wi immediatey remove the drug from the Drug List. We wi et you know of this change right away. Your provider wi aso know about this change, and can work with you to find another drug for your condition. Do changes to your drug coverage affect you right away? If any of the foowing types of changes affect a drug you are taking, the change wi not affect you unti January 1 of the next year if you stay in the pan: If we move your drug into a higher cost-sharing tier. If we put a new restriction on your use of the drug. If we remove your drug from the Drug List, but not because of a sudden reca or because a new generic drug has repaced it. If any of these changes happens for a drug you are taking, then the change won t affect your use or what you pay as your share of the cost unti January 1 of the next year. Unti that date, you probaby won t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes wi affect you. In some cases, you wi be affected by the coverage change before January 1: If a brand name drug you are taking is repaced by a new generic drug, the pan must give you at east 60 days notice or give you a 60-day refi of your brand name drug at a network pharmacy. During this 60-day period, you shoud be working with your provider to switch to the generic or to a different drug that we cover. Or you and your provider can ask the pan 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 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)).

62 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 57 Again, if a drug is suddeny recaed because it s been found to be unsafe or for other reasons, the pan wi immediatey remove the drug from the Drug List. We wi et you know of this change right away. Your provider wi aso know about this change, and can work with you to find another drug for your condition. SECTION 7 Section 7.1 What types of drugs are not covered by the pan? Types of drugs we do not cover This section tes you what kinds of prescription drugs are excuded. This means Medicare does not pay for these drugs. If you get drugs that are excuded, you must pay for them yoursef. We won t pay for the drugs that are isted in this section. The ony exception: If the requested drug is found upon appea to be a drug that is not excuded under Part D and we shoud have paid for or covered it because of your specific situation. (For information about appeaing a decision we have made to not cover a drug, go to Chapter 7, Section 5.5 in this booket.) Here are three genera rues about drugs that Medicare drug pans wi not cover under Part D: Our pan s Part D drug coverage cannot cover a drug that woud be covered under Medicare Part A or Part B. Our pan cannot cover a drug purchased outside the United States and its territories. Our pan usuay cannot cover off-abe use. Off-abe use is any use of the drug other than those indicated on a drug s abe as approved by the Food and Drug Administration. Generay, coverage for off-abe use is aowed ony when the use is supported by certain reference books. These reference books are the American Hospita Formuary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor. If the use is not supported by any of these reference books, then our pan cannot cover its off-abe use. Aso, by aw, these categories of drugs are not covered by Medicare drug pans:

63 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 58 Non-prescription drugs (aso caed over-the-counter drugs) Drugs when used to promote fertiity Drugs when used for the reief of cough or cod symptoms Drugs when used for cosmetic purposes or to promote hair growth Prescription vitamins and minera products, except prenata vitamins and fuoride preparations Drugs when used for the treatment of sexua or erectie dysfunction, such as Viagra, Ciais, Levitra, and Caverject Drugs when used for treatment of anorexia, weight oss, or weight gain Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased excusivey from the manufacturer as a condition of sae If you receive "Extra Hep" paying for your drugs, your state Medicaid program may cover some prescription drugs not normay covered in a Medicare drug pan. Pease contact your state Medicaid program to determine what drug coverage may be avaiabe to you. (You can find phone numbers and contact information for Medicaid in the appendix at the back of this booket.) SECTION 8 Section 8.1 Show your pan membership card when you fi a prescription Show your membership card To fi your prescription, show your pan membership card at the network pharmacy you choose. When you show your pan membership card, the network pharmacy wi automaticay bi the pan for our share of your covered prescription drug cost. You wi 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 card with you? If you don t have your pan membership card with you when you fi your prescription, ask the pharmacy to ca the pan to get the necessary information.

64 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 59 If the pharmacy is not abe to get the necessary information, you may have to pay the fu 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 pan for reimbursement.) SECTION 9 Section 9.1 Part D drug coverage in specia situations What if you re in a hospita or a skied nursing faciity for a stay that is covered by Origina Medicare? If you are admitted to a hospita for a stay covered by Origina Medicare, Medicare Part A wi generay cover the cost of your prescription drugs during your stay. Once you eave the hospita, our pan wi cover your drugs as ong as the drugs meet a of our rues for coverage. See the previous parts of this chapter that te about the rues for getting drug coverage. If you are admitted to a skied nursing faciity for a stay covered by Origina Medicare, Medicare Part A wi generay cover your prescription drugs during a or part of your stay. If you are sti in the skied nursing faciity and Part A is no onger covering your drugs, our pan wi cover your drugs as ong as the drugs meet a of our rues for coverage. See the previous parts of this chapter that te about the rues for getting drug coverage. Pease Note: When you enter, ive in, or eave a skied nursing faciity, you are entited to a Specia Enroment Period. During this time period, you can switch pans or change your coverage. (Chapter 8, Ending your membership in the pan, tes when you can eave our pan and join a different Medicare pan.) Section 9.2 What if you re a resident in a ong-term care (LTC) faciity? Usuay, a ong-term care (LTC) faciity (such as a nursing home) has its own pharmacy, or a pharmacy that suppies drugs for a of its residents. If you are a resident of a ong-term care faciity, you may get your prescription drugs through the faciity s pharmacy as ong as it is part of our network. Check your Pharmacy Directory to find out if your ong-term care faciity s pharmacy is part of our network. If it isn t, or if you need more information, pease contact Customer Service (phone numbers are printed on the back cover of this booket). What if you re a resident in a ong-term care (LTC) faciity and become a new member of the pan?

65 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 60 If you need a drug that is not on our Drug List or is restricted in some way, the pan wi cover a temporary suppy of your drug during the first 98 days of your membership. The tota suppy wi be for a maximum of 98 days, or ess if your prescription is written for fewer days. (Pease note that the ong-term care pharmacy may provide the drug in smaer amounts at a time to prevent waste.) If you have been a member of the pan for more than 98 days and need a drug that is not on our Drug List or if the pan has any restriction on the drug s coverage, we wi cover one 31-day suppy, or ess if your prescription is written for fewer days. During the time when you are getting a temporary suppy of a drug, you shoud tak with your provider to decide what to do when your temporary suppy runs out. Perhaps there is a different drug covered by the pan that might work just as we for you. Or you and your provider can ask the pan to make an exception for you and cover the drug in the way you woud ike it to be covered. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tes what to do. Section 9.3 What if you are taking drugs covered by Origina Medicare? Your enroment in our pan doesn t affect your coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare s coverage requirements, your drug wi sti be covered under Medicare Part A or Part B, even though you are enroed in this pan. In addition, if your drug woud be covered by Medicare Part A or Part B, our pan can t cover it, even if you choose not to enro in Part A or Part B. Some drugs may be covered under Medicare Part B in some situations and through our pan in other situations. But drugs are never covered by both Part B and our pan at the same time. In genera, your pharmacist or provider wi determine whether to bi Medicare Part B or our pan for the drug. Drugs are never covered by both hospice and our pan at the same time. If you are enroed in Medicare hospice and require an anti-nausea, axative, pain medication or antianxiety drug that is not covered by your hospice because it is unreated to your termina iness and reated conditions, our pan must receive notification from either the prescriber or your hospice provider that the drug is unreated before our pan can cover the drug. To prevent deays in receiving any unreated drugs that shoud be covered by our pan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unreated before you ask a pharmacy to fi your prescription. In the event you either revoke your hospice eection or are discharged from hospice, our pan shoud cover a your drugs. To prevent any deays at a pharmacy when your

66 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 61 Medicare hospice benefit ends, you shoud bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this section that te about the rues for getting drug coverage under Part D. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay. Section 9.4 What if you have a Medigap (Medicare Suppement Insurance) poicy with prescription drug coverage? If you currenty have a Medigap poicy that incudes coverage for prescription drugs, you must contact your Medigap issuer and te them you have enroed in our pan. If you decide to keep your current Medigap poicy, your Medigap issuer wi remove the prescription drug coverage portion of your Medigap poicy and ower your premium. Each year your Medigap insurance company shoud send you a notice that tes if your prescription drug coverage is creditabe and the choices you have for drug coverage. (If the coverage from the Medigap poicy is creditabe, it means that it is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage.) The notice wi aso expain how much your premium woud be owered if you remove the prescription drug coverage portion of your Medigap poicy. 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 aso getting drug coverage from an empoyer or retiree group pan? Do you currenty have other prescription drug coverage through your (or your spouse s) empoyer or retiree group? If so, pease contact that group s benefits administrator. He or she can hep you determine how your current prescription drug coverage wi work with our pan. In genera, if you are currenty empoyed, the prescription drug coverage you get from us wi be secondary to your empoyer or retiree group coverage. That means your group coverage woud pay first. Specia note about creditabe coverage : Each year your empoyer or retiree group shoud send you a notice that tes if your prescription drug coverage for the next caendar year is creditabe and the choices you have for drug coverage.

67 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 62 If the coverage from the group pan is creditabe, it means that the pan has drug coverage that is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. Keep these notices about creditabe coverage, because you may need them ater. If you enro in a Medicare pan that incudes Part D drug coverage, you may need these notices to show that you have maintained creditabe coverage. If you didn t get a notice about creditabe coverage from your empoyer or retiree group pan, you can get a copy from the empoyer or retiree group s benefits administrator or the empoyer or union. SECTION 10 Section 10.1 Programs on drug safety and managing medications Programs to hep members use drugs safey We conduct drug use reviews for our members to hep make sure that they are getting safe and appropriate care. These reviews are especiay important for members who have more than one provider who prescribes their drugs. We do a review each time you fi a prescription. We aso review our records on a reguar basis. During these reviews, we ook for potentia probems such as: Possibe medication errors Drugs that may not be necessary because you are taking another drug to treat the same medica condition Drugs that may not be safe or appropriate because of your age or gender Certain combinations of drugs that coud harm you if taken at the same time Prescriptions written for drugs that have ingredients you are aergic to Possibe errors in the amount (dosage) of a drug you are taking If we see a possibe probem in your use of medications, we wi work with your provider to correct the probem. Section 10.2 Medication Therapy Management (MTM) program to hep members manage their medications

68 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 3: Using the pan's coverage for your Part D prescription drugs 63 We have a program that can hep our members with specia situations. For exampe, some members have severa compex medica conditions or they may need to take many drugs at the same time or they coud have very high drug costs. This program is vountary and free to members. A team of pharmacists and doctors deveoped the program for us. This program can hep make sure that our members are using the drugs that work best to treat their medica conditions and hep us identify possibe medication errors. Our program is caed a Medication Therapy Management (MTM) program. Some members who take severa medications for different medica conditions may quaify. A pharmacist or other heath professiona wi give you a comprehensive review of a your medications. You can tak about how best to take your medications, your costs, or any probems you re having. You get a written summary of this discussion. The summary has a medication action pan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any foow-up questions. You aso get a persona medication ist that wi incude a the medications you re taking and why you take them. It s a good idea to schedue your medication review before your yeary Weness visit, so you can tak to your doctor about your action pan and medication ist. Bring your action pan and medication ist with you to your visit or anytime you tak with your doctors, pharmacists, and other heath care providers. Aso, take your medication ist with you if you go to the hospita or emergency room. If we have a program that fits your needs, we wi automaticay enro you in the program and send you information. If you decide not to participate, pease notify us and we wi withdraw you from the program. If you have any questions about these programs, pease contact Customer Service (phone numbers are printed on the back cover of this booket).

69 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 64 Chapter 4. What you pay for your Part D prescription drugs SECTION 1 Introduction...66 Section 1.1 Use this chapter together with other materias that expain your drug coverage...66 Section 1.2 Types of out-of-pocket costs you may pay for covered drugs...67 SECTION 2 What you pay for a drug depends on which drug payment stage you are in when you get the drug...67 Section 2.1 What are the drug payment stages for WeCare Simpe (PDP) members?...67 SECTION 3 We send you reports that expain payments for your drugs and which payment stage you are in...68 Section 3.1 We send you a monthy report caed the Part D Expanation of Benefits (the Part D EOB )...68 Section 3.2 Hep us keep our information about your drug payments up to date.69 SECTION 4 During the Deductibe Stage, you pay the fu cost of your drugs...70 Section 4.1 You stay in the Deductibe Stage unti you have paid $320 for your drugs SECTION 5 During the Initia Coverage Stage, the pan pays its share of 71 your drug costs and you pay your share... Section 5.1 What you pay for a drug depends on the drug and where you fi your prescription...71 Section 5.2 A tabe that shows your costs for a one-month suppy of a drug...72 Section 5.3 If your doctor prescribes ess than a fu month s suppy, you may not have to pay the cost of the entire month s suppy...74 Section 5.4 A tabe that shows your costs for a ong-term (up to a 90-day) suppy of a drug...75 Section 5.5 You stay in the Initia Coverage Stage unti your tota drug costs for the year reach $2,

70 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 65 SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 65% of the costs for generic drugs...78 Section 6.1 You stay in the Coverage Gap Stage unti your out-of-pocket costs reach $4, Section 6.2 How Medicare cacuates your out-of-pocket costs for prescription drugs...79 SECTION 7 During the Catastrophic Coverage Stage, the pan pays most of the cost for your drugs...81 Section 7.1 Once you are in the Catastrophic Coverage Stage, you wi stay in this stage for the rest of the year...81 SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them...81 Section 8.1 Our pan has separate coverage for the Part D vaccine medication itsef and for the cost of giving you the vaccination shot...81 Section 8.2 You may want to ca us at Customer Service before you get a vaccination...83 SECTION 9 Do you have to pay the Part D "ate enroment penaty"?...84 Section 9.1 What is the Part D ate enroment penaty?...84 Section 9.2 How much is the Part D ate enroment penaty?...84 Section 9.3 In some situations, you can enro ate and not have to pay the penaty...85 Section 9.4 What can you do if you disagree about your ate enroment penaty?...86 SECTION 10 Do you have to pay an extra Part D amount because of your income?...87 Section 10.1 Who pays an extra Part D amount because of income?...87 Section 10.2 How much is the extra Part D amount?...87 Section 10.3 What can you do if you disagree about paying an extra Part D amount?...88 Section 10.4 What happens if you do not pay the extra Part D amount?...88

71 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 66? Did you know there are programs to hep peope pay for their drugs? There are programs to hep peope with imited resources pay for their drugs. These incude Extra Hep and State Pharmaceutica Assistance Programs. For more information, see Chapter 2, Section 7. Are you currenty getting hep to pay for your drugs? If you are in a program that heps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs 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.) SECTION 1 Section 1.1 Introduction Use this chapter together with other materias that expain your drug coverage This chapter focuses on what you pay for your Part D prescription drugs. To keep things simpe, we use drug in this chapter to mean a Part D prescription drug. As expained in Chapter 3, not a drugs are Part D drugs some drugs are covered under Medicare Part A or Part B and other drugs are excuded from Medicare coverage by aw. To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fi your prescriptions, and what rues to foow when you get your covered drugs. Here are materias that expain these basics: The pan s List of Covered Drugs (Formuary).To keep things simpe, we ca this the Drug List. This Drug List tes which drugs are covered for you. It aso tes which of the five cost-sharing tiers the drug is in and whether there are any restrictions on your coverage for the drug. If you need a copy of the Drug List, ca Customer Service (phone numbers are printed on the back cover of this booket). You can aso find

72 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 67 the Drug List on our website at The Drug List on the website is aways the most current. Chapter 3 of this booket. Chapter 3 gives the detais about your prescription drug coverage, incuding rues you need to foow when you get your covered drugs. Chapter 3 aso tes which types of prescription drugs are not covered by our pan. The pan s Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 3 for the detais). The Pharmacy Directory has a ist of pharmacies in the pan s network. It aso tes you which pharmacies in our network can give you a ong-term suppy of a drug (such as fiing a prescription for a three-month s suppy). Section 1.2 Types of out-of-pocket costs you may pay for covered drugs To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is caed cost-sharing, and there are three ways you may be asked to pay. The deductibe is the amount you must pay for drugs before our pan begins to pay its share. Co-payment means that you pay a fixed amount each time you fi a prescription. Coinsurance means that you pay a percent of the tota cost of the drug each time you fi a prescription. SECTION 2 Section 2.1 What you pay for a drug depends on which drug payment stage you are in when you get the drug What are the drug payment stages for WeCare Simpe (PDP) members? As shown in the tabe beow, there are drug payment stages for your prescription drug coverage under our pan. How much you pay for a drug depends on which of these stages you are in at the time you get a prescription fied or refied. Keep in mind you are aways responsibe for the pan s monthy premium regardess of the drug payment stage.

73 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 68 Stage 1 Yeary Deductibe Stage You begin in this payment stage when you fi your first prescription of the year. During this stage, you pay the fu cost of your drugs. You stay in this stage unti you have paid $320 for your drugs ($320 is the amount of your deductibe). (Detais are in Section 4 of this chapter.) Stage 2 Initia Coverage Stage During this stage, the pan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage unti your year-to-date tota drug costs (your payments pus any Part D pan s payments) tota $2,960. (Detais are in Section 5 of this chapter.) Stage 3 Coverage Gap Stage During this stage, you pay 45% of the price for brand name drugs (pus a portion of the dispensing fee) and 65% of the price for generic drugs. You stay in this stage unti your year-to-date out-of-pocket costs (your payments) reach a tota of $4,700. This amount and rues for counting costs toward this amount have been set by Medicare. (Detais are in Section 6 of this chapter.) Stage 4 Catastrophic Coverage Stage During this stage, the pan wi pay most of the cost of your drugs for the rest of the caendar year (through December 31, 2015). (Detais are in Section 7 of this chapter.) SECTION 3 Section 3.1 We send you reports that expain payments for your drugs and which payment stage you are in We send you a monthy report caed the Part D Expanation of Benefits (the Part D EOB ) Our pan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions fied or refied at the pharmacy. This

74 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 69 way, we can te you when you have moved from one drug payment stage to the next. In particuar, there are two types of costs we keep track of: We keep track of how much you have paid. This is caed your out-of-pocket cost. We keep track of your tota drug costs. This is the amount you pay out-of-pocket or others pay on your behaf pus the amount paid by the pan. Our pan wi prepare a written report caed the Part D Expanation of Benefits (it is sometimes caed the EOB ) when you have had one or more prescriptions fied through the pan during the previous month. It incudes: Information for that month. This report gives the payment detais about the prescriptions you have fied during the previous month. It shows the tota drugs costs, what the pan paid, and what you and others on your behaf paid. Totas for the year since January 1. This is caed year-to-date information. It shows you the tota drug costs and tota payments for your drugs since the year began. Section 3.2 Hep 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 hep us keep your information correct and up to date: Show your membership card when you get a prescription fied. To make sure we know about the prescriptions you are fiing and what you are paying, show your pan membership card every time you get a prescription fied. Make sure we have the information we need. There are times you may pay for prescription drugs when we wi not automaticay get the information we need to keep track of your out-of-pocket costs. To hep us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are bied for a covered drug, you can ask our pan to pay our share of the cost. For instructions on how to do this, go to Chapter 5, Section 2 of this booket.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a compete record of what you have spent for your drugs:

75 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 70 When you purchase a covered drug at a network pharmacy at a specia price or using a discount card that is not part of our pan s benefit. When you made a co-payment for drugs that are provided under a drug manufacturer patient assistance program. Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the fu price for a covered drug under specia circumstances. Send us information about the payments others have made for you. Payments made by certain other individuas and organizations aso count toward your out-of-pocket costs and hep quaify you for catastrophic coverage. For exampe, payments made by a State Pharmaceutica Assistance Program, an AIDS drug assistance program (ADAP), the Indian Heath Service, and most charities count toward your out-of-pocket costs. You shoud 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 Expanation of Benefits (an EOB) in the mai, pease ook it over to be sure the information is compete and correct. If you think something is missing from the report, or you have any questions, pease ca us at Customer Service (phone numbers are printed on the back cover of this booket). Be sure to keep these reports. They are an important record of your drug expenses. SECTION 4 Section 4.1 During the Deductibe Stage, you pay the fu cost of your drugs You stay in the Deductibe Stage unti you have paid $320 for your drugs The Deductibe Stage is the first payment stage for your drug coverage. This stage begins when you fi your first prescription in the year. When you are in this payment stage, you must pay the fu cost of your drugs unti you reach the pan s deductibe amount, which is $320 for Your fu cost is usuay ower than the norma fu price of the drug, since our pan has negotiated ower costs for most drugs. The deductibe is the amount you must pay for your Part D prescription drugs before the pan begins to pay its share.

76 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 71 Once you have paid $320 for your drugs, you eave the Deductibe Stage and move on to the next drug payment stage, which is the Initia Coverage Stage. SECTION 5 Section 5.1 During the Initia Coverage Stage, the pan pays its share of your drug costs and you pay your share What you pay for a drug depends on the drug and where you fi your prescription During the Initia Coverage Stage, the pan pays its share of the cost of your covered prescription drugs, and you pay your share (your co-payment or coinsurance amount). Your share of the cost wi vary depending on the drug and where you fi your prescription. The pan has five Cost-Sharing Tiers Every drug on the pan s Drug List is in one of five cost-sharing tiers. In genera, the higher the cost-sharing tier number, the higher your cost for the drug: Cost-Sharing Tier 1 (Preferred Generic Drugs) incudes preferred generic drugs. This is the owest cost-sharing tier. Cost-Sharing Tier 2 (Non-Preferred Generic Drugs) incudes non-preferred generic drugs. Cost-Sharing Tier 3 (Preferred Brand Drugs) incudes generic & preferred brand drugs. Cost-Sharing Tier 4 (Non-Preferred Brand Drugs) incudes generic & non-preferred brand drugs. Cost-Sharing Tier 5 (Speciaty Tier Drugs) incudes generic & brand drugs. This is the highest cost-sharing tier. To find out which cost-sharing tier your drug is in, ook it up in the pan s Drug List. Your pharmacy choices How much you pay for a drug depends on whether you get the drug from: A network retai pharmacy that offers standard cost-sharing A network retai pharmacy that offers preferred cost-sharing

77 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 72 A pharmacy that is not in the pan s network The pan s mai service pharmacy For more information about these pharmacy choices and fiing your prescriptions, see Chapter 3 in this booket and the pan s Pharmacy Directory. Generay, we wi cover your prescriptions ony if they are fied at one of our network pharmacies. Some of our network pharmacies aso offer preferred cost-sharing. You may go to either network pharmacies that offer preferred cost-sharing or other network pharmacies that offer standard cost-sharing to receive your covered prescription drugs. Your costs may be ess at pharmacies that offer preferred cost-sharing. Section 5.2 A tabe that shows your costs for a one-month suppy of a drug During the Initia Coverage Stage, your share of the cost of a covered drug wi be either a co-payment or coinsurance. Co-payment means that you pay a fixed amount each time you fi a prescription. Coinsurance means that you pay a percent of the tota cost of the drug each time you fi a prescription. As shown in the tabe beow, the amount of the co-payment or coinsurance depends on which tier your drug is in. Pease note: If your covered drug costs ess than the co-payment amount isted in the chart, you wi pay that ower price for the drug. You pay either the fu price of the drug or the co-payment amount, whichever is ower. We cover prescriptions fied at out-of-network pharmacies in ony imited situations. Pease see Chapter 3, Section 2.5 for information about when we wi cover a prescription fied at an out-of-network pharmacy.

78 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 73 Your share of the cost when you get a one-month suppy of a covered Part D prescription drug from: Tier Cost-Sharing Tier 1 (Preferred Generic Drugs), which incudes preferred generic drugs Cost-Sharing Tier 2 (Non-Preferred Generic Drugs), which incudes non-preferred generic drugs Cost-Sharing Tier 3 (Preferred Brand Drugs), which incudes generic & preferred brand drugs Standard retai and mai service cost-sharing (in-network) (up to a 30-day suppy) Preferred retai cost-sharing (in-network) (up to a 30-day suppy) Preferred mai service cost-sharing (up to a 30-day suppy) Long-term care (LTC) cost-sharing (up to a 31-day suppy) Out-ofnetwork cost-sharing (Coverage is imited to certain situations; see Chapter 3 for detais.) (up to a 30-day suppy) $9 $0 $0 $9 $9 $25 - $29 $2 - $6 $2 - $6 $25 - $29 $25 - $29 $45 $35 - $40 $35 - $40 $45 $45

79 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 74 Tier Cost-Sharing Tier 4 (Non-Preferred Brand Drugs), which incudes generic & non-preferred brand drugs Standard retai and mai service cost-sharing (in-network) (up to a 30-day suppy) Preferred retai cost-sharing (in-network) (up to a 30-day suppy) Preferred mai service cost-sharing (up to a 30-day suppy) Long-term care (LTC) cost-sharing (up to a 31-day suppy) Out-ofnetwork cost-sharing (Coverage is imited to certain situations; see Chapter 3 for detais.) (up to a 30-day suppy) $95 $84 - $94 $84 - $94 $95 $95 Cost-Sharing Tier 5 (Speciaty Tier Drugs),which 25% 25% 25% 25% 25% incudes generic & brand drugs (Refer to the appendix at the back of this booket for the exact cost-sharing amount for your state.) Section 5.3 If your doctor prescribes ess than a fu month s suppy, you may not have to pay the cost of the entire month s suppy Typicay, you pay a co-pay to cover a fu month s suppy of a covered drug. However, your doctor can prescribe ess than a month s suppy of drugs. There may be times when you want to ask your doctor about prescribing ess than a month s suppy of a drug (for exampe, when you are trying a medication for the

80 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 75 first time that is known to have serious side effects). If you doctor agrees, you wi not have to pay for the fu month s suppy for certain drugs. The amount you pay when you get ess than a fu month s suppy wi depend on whether you are responsibe for paying coinsurance (a percentage of the tota cost) or a co-payment (a fat doar amount). If you are responsibe for coinsurance, you pay a percentage of the tota cost of the drug. You pay the same percentage regardess of whether the prescription is for a fu month s suppy or for fewer days. However, because the entire drug cost wi be ower if you get ess than a fu month s suppy, the amount you pay wi be ess. If you are responsibe for a co-payment for the drug, your co-pay wi be based on the number of days of the drug that you receive. We wi cacuate the amount you pay per day for your drug (the daiy cost-sharing rate ) and mutipy it by the number of days of the drug you receive. Here s an exampe: Let s say the co-pay for your drug for a fu month s suppy (a 30-day suppy) is $30. This means that the amount you pay per day for your drug is $1. If you receive a 7 days suppy of the drug, your payment wi be $1 per day mutipied by 7 days, for a tota payment of $7. You shoud not have to pay more per day just because you begin with ess than a month s suppy. Let s go back to the exampe above. Let s say you and your doctor agree that the drug is working we and that you shoud continue taking the drug after your 7 days suppy runs out. If you receive a second prescription for the rest of the month, or 23 days more of the drug, you wi sti pay $1 per day, or $23. Your tota cost for the month wi be $7 for your first prescription and $23 for your second prescription, for a tota of $30 the same as your co-pay woud be for a fu month s suppy. Daiy cost-sharing aows you to make sure a drug works for you before you have to pay for an entire month s suppy. Section 5.4 A tabe that shows your costs for a ong-term (up to a 90-day) suppy of a drug For some drugs, you can get a ong-term suppy (aso caed an extended suppy ) when you fi your prescription. A ong-term suppy is up to a 90-day suppy. (For detais on where and how to get a ong-term suppy of a drug, see Chapter 3, Section 2.4.)

81 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 76 The tabe beow shows what you pay when you get a ong-term (up to a 90-day) suppy of a drug. Pease note: If your covered drug costs ess than the co-payment amount isted in the chart, you wi pay that ower price for the drug. You pay either the fu price of the drug or the co-payment amount, whichever is ower. Your share of the cost when you get a ong-term suppy of a covered Part D prescription drug from: Tier Cost-Sharing Tier 1 (Preferred Generic Drugs), which incudes preferred generic drugs Cost-Sharing Tier 2 (Non-Preferred Generic Drugs), which incudes non-preferred generic drugs Cost-Sharing Tier 3 (Preferred Brand Drugs), which incudes generic & preferred brand drugs Standard retai and mai service cost-sharing (in-network) (up to a 90-day suppy) Preferred retai cost-sharing (in-network) (up to a 90-day suppy) Preferred mai service cost-sharing (up to a 90-day suppy) $27 $0 $0 $75 - $87 $6 - $18 $5 - $15 $135 $105 - $120 $ $100

82 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 77 Standard retai and mai service cost-sharing (in-network) (up to a 90-day suppy) Preferred retai cost-sharing (in-network) (up to a 90-day suppy) Preferred mai service cost-sharing (up to a 90-day suppy) Tier Cost-Sharing Tier 4 (Non-Preferred Brand Drugs), which incudes generic & non-preferred brand drugs $285 $252 - $282 $210 - $235 Cost-Sharing Tier 5 (Speciaty Tier Drugs),which incudes generic & brand drugs A ong-term suppy is not avaiabe for drugs in Tier 5 A ong-term suppy is not avaiabe for drugs in Tier 5 A ong-term suppy is not avaiabe for drugs in Tier 5 (Refer to the appendix at the back of this booket for the exact cost-sharing amount for your state.) Section 5.5 You stay in the Initia Coverage Stage unti your tota drug costs for the year reach $2,960 You stay in the Initia Coverage Stage unti the tota amount for the prescription drugs you have fied and refied reaches the $2,960, imit for the Initia Coverage Stage. Your tota drug cost is based on adding together what you have paid and what any Part D pan has paid: What you have paid for a the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare cacuates your out-of-pocket costs.) This incudes: The $320 you paid when you were in the Deductibe Stage.

83 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 78 The tota you paid as your share of the cost for your drugs during the Initia Coverage Stage. What the pan has paid as its share of the cost for your drugs during the Initia Coverage Stage. (If you were enroed in a different Part D pan at any time during 2015, the amount that pan paid during the Initia Coverage Stage aso counts toward your tota drug costs.) The Expanation of Benefits (EOB) that we send to you wi hep you keep track of how much you and the pan have spent for your drugs during the year. Many peope do not reach the $2,960 imit in a year. We wi et you know if you reach this $2,960 amount. If you do reach this amount, you wi eave the Initia Coverage Stage and move on to the Coverage Gap Stage. SECTION 6 Section 6.1 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 65% of the costs for generic drugs You stay in the Coverage Gap Stage unti your out-of-pocket costs reach $4,700 When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs. You pay 45% of the negotiated price (excuding the dispensing fee and vaccine administration fee, if any) 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 moves you through the coverage gap. You aso receive some coverage for generic drugs. You pay no more than 65% of the cost for generic drugs and the pan pays the rest. For generic drugs, the amount paid by the pan (35%) does not count toward your out-of-pocket costs. Ony the amount you pay counts and moves you through the coverage gap. You continue paying the discounted price for brand name drugs and no more than 65% of the costs of generic drugs unti your yeary out-of-pocket payments reach a maximum amount that Medicare has set. In 2015, that amount is $4,700. Medicare has rues about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket imit of $4,700, you eave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

84 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 79 Section 6.2 How Medicare cacuates your out-of-pocket costs for prescription drugs Here are Medicare s rues that we must foow when we keep track of your out-of-pocket costs for your drugs. These payments are incuded in your out-of-pocket costs When you add up your out-of-pocket costs, you can incude the payments isted beow (as ong as they are for Part D covered drugs and you foowed the rues for drug coverage that are expained in Chapter 3 of this booket): The amount you pay for drugs when you are in any of the foowing drug payment stages: The Deductibe Stage. The Initia Coverage Stage. The Coverage Gap Stage. Any payments you made during this caendar year as a member of a different Medicare prescription drug pan before you joined our pan. It matters who pays: If you make these payments yoursef, they are incuded in your out-of-pocket costs. These payments are aso incuded if they are made on your behaf by certain other individuas or organizations. This incudes payments for your drugs made by a friend or reative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutica Assistance Program that is quaified by Medicare, or by the Indian Heath Service. Payments made by Medicare s Extra Hep Program are aso incuded. Some of the payments made by the Medicare Coverage Gap Discount Program are incuded. The amount the manufacturer pays for your brand-name drugs is incuded. But the amount the pan pays for your generic drugs is not incuded. Moving on to the Catastrophic Coverage Stage:

85 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 80 When you (or those paying on your behaf) have spent a tota of $4,700 in out-of-pocket costs within the caendar year, you wi move from the Coverage Gap Stage to the Catastrophic Coverage Stage. These payments are not incuded in your out-of-pocket costs When you add up your out-of-pocket costs, you are not aowed to incude any of these types of payments for prescription drugs: The amount you pay for your monthy premium. Drugs you buy outside the United States and its territories. Drugs that are not covered by our pan. Drugs you get at an out-of-network pharmacy that do not meet the pan s requirements for out-of-network coverage. Non-Part D drugs, incuding prescription drugs covered by Part A or Part B and other drugs excuded from coverage by Medicare. Payments you make toward prescription drugs not normay covered in a Medicare Prescription Drug Pan. Payments made by the pan for your brand or generic drugs whie in the Coverage Gap. Payments for your drugs that are made by group heath pans incuding empoyer heath pans. Payments for your drugs that are made by certain insurance pans and government-funded heath programs such as TRICARE and the Veteran s Administration. Payments for your drugs made by a third-party with a ega obigation to pay for prescription costs (for exampe, Worker s Compensation). Reminder: If any other organization such as the ones isted above pays part or a of your out-of-pocket costs for drugs, you are required to te our pan. Ca Customer Service to et us know (phone numbers are printed on the back cover of this booket). How can you keep track of your out-of-pocket tota? We wi hep you. The Part D Expanation of Benefits (Part D EOB) report we send to you incudes the current amount of your out-of-pocket costs (Section 3 in this chapter tes about this report). When you reach a tota of $4,700 in out-of-pocket costs for the year, this report wi te you that you

86 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 81 have eft the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. Make sure we have the information we need. Section 3.2 tes what you can do to hep make sure that our records of what you have spent are compete and up to date. SECTION 7 Section 7.1 During the Catastrophic Coverage Stage, the pan pays most of the cost for your drugs Once you are in the Catastrophic Coverage Stage, you wi stay in this stage for the rest of the year You quaify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4,700 imit for the caendar year. Once you are in the Catastrophic Coverage Stage, you wi stay in this payment stage unti the end of the caendar year. During this stage, the pan wi pay most of the cost for your drugs. Your share of the cost for a covered drug wi be either coinsurance or a co-payment, whichever is the arger amount: either coinsurance of 5% of the cost of the drug or $2.65 for a generic drug or a drug that is treated ike a generic and $6.60 for a other drugs. Our pan pays the rest of the cost. SECTION 8 Section 8.1 What you pay for vaccinations covered by Part D depends on how and where you get them Our pan has separate coverage for the Part D vaccine medication itsef and for the cost of giving you the vaccination shot Our pan provides coverage of a number of Part D vaccines. There are two parts to our coverage of vaccinations: The first part of coverage is the cost of the vaccine medication itsef. The vaccine is a prescription medication.

87 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 82 The second part of coverage is for the cost of giving you the vaccination shot. (This is sometimes caed the administration of the vaccine.) What do you pay for a Part D vaccination? What you pay for a Part D vaccination depends on three things: 1. The type of vaccine (what you are being vaccinated for). Some vaccines are considered Part D drugs. You can find these vaccines isted in the pan s List of Covered Drugs (Formuary). Other vaccines are considered medica benefits. They are covered under Origina Medicare. 2. Where you get the vaccine medication. 3. Who gives you the vaccination shot. What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For exampe: Sometimes when you get your vaccination shot, you wi have to pay the entire cost for both the vaccine medication and for getting the vaccination shot. You can ask our pan to pay you back for our share of the cost. Other times, when you get the vaccine medication or the vaccination shot, you wi pay ony your share of the cost. To show how this works, here are three common ways you might get a Part D vaccination shot. Remember you are responsibe for a of the costs associated with vaccines (incuding their administration) during the Deductibe Stage and Coverage Gap Stage of your benefit. Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you ive. Some states do not aow pharmacies to administer a vaccination.) You wi have to pay the pharmacy the amount of your co-payment or coinsurance for the vaccine and the cost of giving you the vaccination shot. Our pan wi pay the remainder of the costs. Situation 2: You get the Part D vaccination at your doctor s office.

88 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs When you get the vaccination, you wi pay for the entire cost of the vaccine and its administration. You can then ask our pan to pay our share of the cost by using the procedures that are described in Chapter 5 of this booket (Asking us to pay our share of the costs for covered drugs). You wi be reimbursed the amount you paid ess your norma coinsurance or co-payment for the vaccine (incuding administration) ess any difference between the amount the doctor charges and what we normay pay. (If you get "Extra Hep", we wi reimburse you for this difference.) Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor s office where they give you the vaccination shot. You wi have to pay the pharmacy the amount of your coinsurance or co-payment for the vaccine itsef. When your doctor gives you the vaccination shot, you wi pay the entire cost for this service. You can then ask our pan to pay our share of the cost by using the procedures described in Chapter 5 of this booket. You wi be reimbursed the amount charged by the doctor for administering the vaccine ess any difference between the amount the doctor charges and what we normay pay. (If you get "Extra Hep", we wi reimburse you for this difference.) 83 Section 8.2 You may want to ca us at Customer Service before you get a vaccination The rues for coverage of vaccinations are compicated. We are here to hep. We recommend that you ca us first at Customer Service whenever you are panning to get a vaccination. (Phone numbers for Customer Service are printed on the back cover of this booket.) We can te you about how your vaccination is covered by our pan and expain your share of the cost. We can te you how to keep your own cost down by using providers and pharmacies in our network.

89 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs If you are not abe to use a network provider and pharmacy, we can te you what you need to do to get payment from us for our share of the cost. 84 SECTION 9 Section 9.1 Do you have to pay the Part D ate enroment penaty? What is the Part D ate enroment penaty? Note: If you receive Extra Hep from Medicare to pay for your prescription drugs, you wi not pay a ate enroment penaty. The ate enroment penaty is an amount that is added to your Part D premium. You may owe a ate enroment penaty if at any time after your initia enroment period is over, there is a period of 63 days or more in a row when you did not have Part D or other creditabe prescription drug coverage. Creditabe prescription drug coverage is coverage that meets Medicare s minimum standards since it is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. The amount of the penaty depends on how ong you waited to enro in a creditabe prescription drug coverage pan any time after the end of your initia enroment period or how many fu caendar months you went without creditabe prescription drug coverage. You wi have to pay this penaty for as ong as you have Part D coverage. The penaty is added to your monthy premium. When you first enro in our pan, we et you know the amount of the penaty. Your ate enroment penaty is considered part of your pan premium. If you do not pay your ate enroment penaty, you coud be disenroed for faiure to pay your pan premium. Section 9.2 How much is the Part D ate enroment penaty? Medicare determines the amount of the penaty. Here is how it works: First count the number of fu months that you deayed enroing in a Medicare drug pan, after you were eigibe to enro. Or count the number of fu months in which you did not have creditabe prescription drug coverage, if the break in coverage was 63 days or more. The penaty is 1% for every

90 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 85 month that you didn t have creditabe coverage. For exampe, if you go 14 months without coverage, the penaty wi be 14%. Then Medicare determines the amount of the average monthy premium for Medicare drug pans in the nation from the previous year. For 2014, this average premium amount was $ This amount may change for To cacuate your monthy penaty, you mutipy the penaty percentage and the average monthy premium and then round it to the nearest 10 cents. In the exampe here it woud be 14% times $32.42, which equas $ This rounds to $4.50. This amount woud be added to the monthy premium for someone with a ate enroment penaty. There are three important things to note about this monthy ate enroment penaty: First, the penaty may change each year, because the average monthy premium can change each year. If the nationa average premium (as determined by Medicare) increases, your penaty wi increase. Second, you wi continue to pay a penaty every month for as ong as you are enroed in a pan that has Medicare Part D drug benefits. Third, if you are under 65 and currenty receiving Medicare benefits, the ate enroment penaty wi reset when you turn 65. After age 65, your ate enroment penaty wi be based ony on the months that you don t have coverage after your initia enroment period for aging into Medicare. Section 9.3 In some situations, you can enro ate and not have to pay the penaty Even if you have deayed enroing in a pan offering Medicare Part D coverage when you were first eigibe, sometimes you do not have to pay the ate enroment penaty. You wi not have to pay a penaty for ate enroment if you are in any of these situations: If you aready have prescription drug coverage that is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. Medicare cas this creditabe drug coverage. Pease note: Creditabe coverage coud incude drug coverage from a former empoyer or union, TRICARE, or the Department of Veterans Affairs. Your insurer or your human resources department wi te you each year if your drug

91 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 86 coverage is creditabe coverage. This information may be sent to you in a etter or incuded in a newsetter from the pan. Keep this information, because you may need it if you join a Medicare drug pan ater. u Pease note: If you receive a certificate of creditabe coverage when your heath coverage ends, it may not mean your prescription drug coverage was creditabe. The notice must state that you had creditabe prescription drug coverage that's expected to pay as much as Medicare s standard prescription drug pan pays. The foowing are not creditabe prescription drug coverage: prescription drug discount cards, free cinics, and drug discount websites. For additiona information about creditabe coverage, pease ook in your Medicare & You 2015 Handbook or ca Medicare at MEDICARE ( ). TTY users ca You can ca these numbers for free, 24 hours a day, 7 days a week. If you were without creditabe coverage, but you were without it for ess than 63 days in a row. If you are receiving Extra Hep from Medicare. Section 9.4 What can you do if you disagree about your ate enroment penaty? If you disagree about your ate enroment penaty, you or your representative can ask for a review of the decision about your ate enroment penaty. Generay, you must request this review within 60 days from the date on the etter you receive stating you have to pay a ate enroment penaty. Ca Customer Service to find out more about how to do this (phone numbers are printed on the back cover of this booket). Important: Do not stop paying your ate enroment penaty whie you re waiting for a review of the decision about your ate enroment penaty. If you do, you coud be disenroed for faiure to pay your pan premiums.

92 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 87 SECTION 10 Section 10.1 Do you have to pay an extra Part D amount because of your income? Who pays an extra Part D amount because of income? Most peope pay a standard monthy Part D premium. However, some peope pay an extra amount because of their yeary income. 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 for your Medicare Part D 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 and how to pay it. The extra amount wi be withhed from your Socia Security, Rairoad Retirement Board, or Office of Personne Management benefit check, no matter how you usuay pay your pan premium, uness your monthy benefit isn t enough to cover the extra amount owed. If your benefit check isn t enough to cover the extra amount, you wi get a bi from Medicare. You must pay the extra amount to the government. It cannot be paid with your monthy pan premium. Section 10.2 How much is the extra Part D amount? If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a certain amount, you wi pay an extra amount in addition to your monthy pan premium. The chart beow shows the extra amount based on your income. If you fied an individua tax return and your income in 2013 was: If you were married but fied a separate tax return and your income in 2013 was: If you fied a joint tax return and your income in 2013 was: This is the monthy cost of your extra Part D amount (to be paid in addition to your pan premium) Equa to or ess than $85,000 Equa to or ess than $85,000 Equa to or ess than $170,000 $0

93 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 4: What you pay for your Part D prescription drugs 88 If you fied an individua tax return and your income in 2013 was: If you were married but fied a separate tax return and your income in 2013 was: If you fied a joint tax return and your income in 2013 was: This is the monthy cost of your extra Part D amount (to be paid in addition to your pan premium) Greater than $85,000 and ess than or equa to $107,000 Greater than $170,000 and ess than or equa to $214,000 $12.30 Greater than $107,000 and ess than or equa to $160,000 Greater than $214,000 and ess than or equa to $320,000 $31.80 Greater than $160,000 and ess than or equa to $214,000 Greater than $85,000 and ess than or equa to $129,000 Greater than $320,000 and ess than or equa to $428,000 $51.30 Greater than $214,000 Greater than $129,000 Greater than $428,000 $70.80 Section 10.3 What can you do if you disagree about paying an extra Part D amount? If you disagree about paying an extra amount because of your income, you can ask Socia Security to review the decision. To find out more about how to do this, contact Socia Security at (TTY ). Section 10.4 What happens if you do not pay the extra Part D amount? The extra amount is paid directy to the government (not your 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.

94 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 5: Asking us to pay our share of the costs for covered drugs 89 Chapter 5. Asking us to pay our share of the costs for covered drugs SECTION 1 Situations in which you shoud ask us to pay our share of the cost of your covered drugs Section 1.1 If you pay our pan s share of the cost of your covered drugs, you can ask us for payment SECTION 2 How to ask us to pay you back Section 2.1 How and where to send us your request for payment SECTION 3 We wi consider your request for payment and say yes or no Section 3.1 We check to see whether we shoud cover the drug and how much we owe Section 3.2 If we te you that we wi not pay for a or part of the drug, you can make an appea SECTION 4 Other situations in which you shoud save your receipts and send copies to us Section 4.1 In some cases, you shoud send copies of your receipts to us to hep us track your out-of-pocket drug costs... 93

95 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 5: Asking us to pay our share of the costs for covered drugs 90 SECTION 1 Section 1.1 Situations in which you shoud ask us to pay our share of the cost of your covered drugs If you pay our pan s share of the cost of your covered drugs, you can ask us for payment Sometimes when you get a prescription drug, you may need to pay the fu cost right away. Other times, you may find that you have paid more than you expected under the coverage rues of the pan. In either case, you can ask our pan to pay you back (paying you back is often caed reimbursing you). Here are exampes of situations in which you may need to ask our pan to pay you back. A of these exampes are types of coverage decisions (for more information about coverage decisions, go to Chapter 7 of this booket). 1. When you use an out-of-network pharmacy to get a prescription fied If you go to an out-of-network pharmacy and try to use your membership card to fi a prescription, the pharmacy may not be abe to submit the caim directy to us. When that happens, you wi have to pay the fu cost of your prescription. (We cover prescriptions fied at out-of-network pharmacies ony in a few specia situations. Pease go to Chapter 3, Sec. 2.5 to earn more.) Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 2. When you pay the fu cost for a prescription because you don t have your pan membership card with you If you do not have your pan membership card with you, you can ask the pharmacy to ca the pan or ook up your enroment information. However, if the pharmacy cannot get the enroment information they need right away, you may need to pay the fu cost of the prescription yoursef. 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 fu cost for a prescription in other situations You may pay the fu cost of the prescription because you find that the drug is not covered for some reason. For exampe, the drug may not be on the pan s List of Covered Drugs (Formuary); or it coud have a requirement or restriction that you didn t know

96 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 5: Asking us to pay our share of the costs for covered drugs 91 about or don t think shoud appy to you. If you decide to get the drug immediatey, you may need to pay the fu 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. 4. If you are retroactivey enroed in our pan. Sometimes a person s enroment in the pan is retroactive. (Retroactive means that the first day of their enroment has aready passed. The enroment date may even have occurred ast year.) If you were retroactivey enroed in our pan and you paid out-of-pocket for any of your drugs after your enroment date, you can ask us to pay you back for our share of the costs. You wi need to submit paperwork for us to hande the reimbursement. Pease ca Customer Service for additiona information about how to ask us to pay you back and deadines for making your request. (Phone numbers for Customer Service are printed on the back cover of this booket.) A of the exampes above are types of coverage decisions. This means that if we deny your request for payment, you can appea our decision. Chapter 7 of this booket (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)) has information about how to make an appea. SECTION 2 Section 2.1 How to ask us to pay you back How and where to send us your request for payment Send us your request for payment, aong with your receipt documenting the payment you have made. It s a good idea to make a copy of your receipts for your records. Mai your request for payment together with any receipts to us at this address: WeCare Prescription Reimbursement Department P.O. Box 31577, Tampa, FL Contact Customer Service if you have any questions (phone numbers are printed on the back cover of this booket.). If you don t know what you shoud have paid,

97 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 5: Asking us to pay our share of the costs for covered drugs 92 we can hep. You can aso ca if you want to give us more information about a request for payment you have aready sent to us. SECTION 3 Section 3.1 We wi consider your request for payment and say yes or no We check to see whether we shoud cover the drug and how much we owe When we receive your request for payment, we wi et you know if we need any additiona information from you. Otherwise, we wi consider your request and make a coverage decision. If we decide that the drug is covered and you foowed a the rues for getting the drug, we wi pay for our share of the cost. We wi mai your reimbursement of our share of the cost to you. (Chapter 3 expains the rues you need to foow for getting your Part D prescription drugs covered.) We wi send payment within 30 days after your request was received. If we decide that the drug is not covered, or you did not foow a the rues, we wi not pay for our share of the cost. Instead, we wi send you a etter that expains the reasons why we are not sending the payment you have requested and your rights to appea that decision. Section 3.2 If we te you that we wi not pay for a or part of the drug, you can make an appea If you think we have made a mistake in turning down your request for payment or you don t agree with the amount we are paying, you can make an appea. If you make an appea, it means you are asking us to change the decision we made when we turned down your request for payment. For the detais on how to make this appea, go to Chapter 7 of this booket (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). The appeas process is a forma process with detaied procedures and important deadines. If making an appea is new to you, you wi find it hepfu to start by reading Section 4 of Chapter 7. Section 4 is an introductory section that expains the process for coverage decisions and appeas and gives definitions of terms such as appea. Then after you have read Section 4, you can go to Section 5.5 in Chapter 7 for a step-by-step expanation of how to fie an appea.

98 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 5: Asking us to pay our share of the costs for covered drugs 93 SECTION 4 Section 4.1 Other situations in which you shoud save your receipts and send copies to us In some cases, you shoud send copies of your receipts to us to hep us track your out-of-pocket drug costs There are some situations when you shoud et us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are teing us about your payments so that we can cacuate your out-of-pocket costs correcty. This may hep you to quaify for the Catastrophic Coverage Stage more quicky. Here are two situations when you shoud send us copies of receipts to et us know about payments you have made for your drugs: 1. When you buy the drug for a price that is ower than our price Sometimes when you are in the Deductibe Stage or Coverage Gap Stage you can buy your drug at a network pharmacy for a price that is ower than our price. For exampe, a pharmacy might offer a specia price on the drug. Or you may have a discount card that is outside our benefit that offers a ower price. Uness specia conditions appy, you must use a network pharmacy in these situations and your drug must be on our Drug List. Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward quaifying you for the Catastrophic Coverage Stage. Pease note: If you are in the Deductibe Stage or Coverage Gap Stage, we wi not pay for any share of these drug costs. But sending a copy of the receipt aows us to cacuate your out-of-pocket costs correcty and may hep you quaify for the Catastrophic Coverage Stage more quicky. 2. When you get a drug through a patient assistance program offered by a drug manufacturer Some members are enroed in a patient assistance program offered by a drug manufacturer that is outside the pan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a co-payment to the patient assistance program.

99 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 5: Asking us to pay our share of the costs for covered drugs 94 Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward quaifying you for the Catastrophic Coverage Stage. Pease note: Because you are getting your drug through the patient assistance program and not through the pan s benefits, we wi not pay for any share of these drug costs. But sending a copy of the receipt aows us to cacuate your out-of-pocket costs correcty and may hep you quaify for the Catastrophic Coverage Stage more quicky. Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Therefore, you cannot make an appea if you disagree with our decision.

100 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 95 Chapter 6. Your rights and responsibiities SECTION 1 Our pan must honor your rights as a member of the pan Section 1.1 We must provide information in a way that works for you (in anguages other than Engish, in Braie, or other aternate formats, etc.) Section 1.2 We must treat you with fairness and respect at a times Section 1.3 We must ensure that you get timey access to your covered drugs.97 Section 1.4 We must protect the privacy of your persona heath information Section 1.5 We must give you information about the pan, its network of pharmacies, and your covered drugs Section 1.6 We must support your right to make decisions about your care Section 1.7 You have the right to make compaints and to ask us to reconsider decisions we have made Section 1.8 What can you do if you beieve you are being treated unfairy or your rights are not being respected? Section 1.9 How to get more information about your rights SECTION 2 You have some responsibiities as a member of the pan Section 2.1 What are your responsibiities?

101 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 96 SECTION 1 Section 1.1 Our pan must honor your rights as a member of the pan We must provide information in a way that works for you (in anguages other than Engish, in Braie, or other aternate formats, etc.) To get information from us in a way that works for you, pease ca Customer Service (phone numbers are printed on the back cover of this booket). Our pan has peope and free anguage interpreter services avaiabe to answer questions from non-engish speaking members. We aso have materias avaiabe in anguages other than Engish that are spoken in the pan s service area. We can aso give you information in Braie or other aternate formats if you need it. If you are eigibe for Medicare because of disabiity, we are required to give you information about the pan s benefits that is accessibe and appropriate for you. If you have any troube getting information from our pan because of probems reated to anguage or disabiity, pease ca Medicare at MEDICARE ( ), 24 hours a day, 7 days a week, and te them that you want to fie a compaint. TTY users ca Para obtener información de nosotros de una manera comprensibe para usted, por favor ame a Servicio a Ciente (os números de teéfono están indicados en a parte posterior de este foeto). Nuestro pan tiene personas y servicios disponibes de interpretación a otros idiomas gratis para responder as preguntas de aqueos miembros que no haban ingés. También tenemos materiaes disponibes en idiomas diferentes de ingés que se haban en e área de servicio de pan. También podemos dare información en Braie u otros formatos aternativos si os necesita. Si usted es eegibe para Medicare por discapacidad, tenemos a obigación de brindare información sobre os beneficios de pan que sea accesibe y adecuada para usted. Si tiene probemas para obtener información sobre nuestro pan debido a idioma o discapacidad, por favor ame a Medicare a MEDICARE ( ) as 24 horas de día, os 7 días de a semana, y dígaes que desea presentar una queja. Los usuarios de TTY amen a

102 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 97 Section 1.2 We must treat you with fairness and respect at a times Our pan must obey aws that protect you from discrimination or unfair treatment. We do not discriminate based on a person s race, ethnicity, nationa origin, reigion, gender, age, menta or physica disabiity, heath status, caims experience, medica history, genetic information, evidence of insurabiity, or geographic ocation within the service area. If you want more information or have concerns about discrimination or unfair treatment, pease ca the Department of Heath and Human Services Office for Civi Rights (TTY ) or your oca Office for Civi Rights. If you have a disabiity and need hep with access to care, pease ca us at Customer Service (phone numbers are printed on the back cover of this booket). If you have a compaint, such as a probem with wheechair access, Customer Service can hep. Section 1.3 We must ensure that you get timey access to your covered drugs As a member of our pan, you aso have the right to get your prescriptions fied or refied at any of our network pharmacies without ong deays. If you think that you are not getting your Part D drugs within a reasonabe amount of time, Chapter 7, Section 7 of this booket tes what you can do. (If we have denied coverage for your prescription drugs and you don t agree with our decision, Chapter 7, Section 4 tes what you can do.) Section 1.4 We must protect the privacy of your persona heath information 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. Your persona heath information incudes the persona information you gave us when you enroed in this pan as we as your medica records and other medica and heath information.

103 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 98 The aws that protect your privacy give you rights reated to getting information and controing how your heath information is used. We give you a written notice, caed a Notice of Privacy Practice, that tes about these rights and expains how we protect the privacy of your heath information. How do we protect the privacy of your heath information? We make sure that unauthorized peope don t see or change your records. In most situations, if we give your heath information to anyone who isn t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given ega power to make decisions for you. There are certain exceptions that do not require us to get your written permission first. These exceptions are aowed or required by aw. For exampe, we are required to reease heath information to government agencies that are checking on quaity of care. Because you are a member of our pan through Medicare, we are required to give Medicare your heath information incuding information about your Part D prescription drugs. If Medicare reeases your information for research or other uses, this wi be done according to Federa statutes and reguations. You can see the information in your records and know how it has been shared with others You have the right to ook at your medica records hed at the pan, and to get a copy of your records. We are aowed to charge you a fee for making copies. You aso have the right to ask us to make additions or corrections to your medica records. If you ask us to do this, we wi work with your heathcare provider to decide whether the changes shoud be made. You have the right to know how your heath information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your persona heath information, pease ca Customer Service (phone numbers are printed on the back cover of this booket).

104 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 99 WeCare Notice of Privacy Practices This notice describes how medica information about you may be used and discosed and how you can get access to this information. Pease review it carefuy. Effective Date of this Privacy Notice: March 29, 2012 Revised as of August, 2013 We are required by aw to protect the privacy of heath information that may revea your identity. We are aso required by aw to provide you with a copy of this Privacy Notice which describes our ega duties and heath information privacy practices, as we as the rights you have with respect to your heath information. This Privacy Notice appies to the foowing WeCare entities: Easy Choice Heath Pan, Inc. Exactus Pharmacy Soutions, Inc. Harmony Heath Pan of Iinois, Inc. Harmony Heath Pan of Iinois, Inc., operating in Missouri as Harmony Heath Pan of Missouri Missouri Care, Incorporated WeCare Heath Insurance of Arizona, Inc., operating in Hawai i as Ohana Heath Pan, Inc. WeCare Heath Insurance Company of Kentucky, Inc., operating in Kentucky as WeCare of Kentucky, Inc. WeCare Heath Pans of New Jersey, Inc. WeCare of Connecticut, Inc. WeCare of Forida, Inc., operating in Forida as HeathEase and Staywe WeCare of Georgia, Inc. WeCare of Louisiana, Inc. WeCare of New York, Inc. WeCare of Ohio, Inc. WeCare of South Caroina, Inc. WeCare of Texas, Inc., operating in Arizona as WeCare of Arizona, Inc. WeCare Prescription Insurance, Inc. Windsor Heath Pan, Inc. Stering Life Insurance Company We may change our privacy practices from time to time. If we make any materia revisions to this Privacy Notice, we wi provide you with a copy of the revised Privacy Notice which wi specify the date on which such revised Privacy Notice becomes effective. The revised Privacy Notice wi appy to a of your heath information from and after the date of the Privacy Notice NA022734_CAD_FRM_ENG State Approved WeCare 2013 NA_08_13_V1 CADHIPINS55998E_0813

105 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 100 How We May Use and Discose Your Heath Information without Written Authorization WeCare requires its empoyees to foow its privacy and security poicies and procedures to protect your heath information in ora (for exampe, when discussing your heath information with authorized individuas over the teephone or in person), written or eectronic form. The foowing are situations where we do not need your written authorization to use your heath information or to share it with others. 1. Treatment, Payment, and Business Operations. We may use your heath information or share it with others to hep treat your condition, coordinate payment for that treatment, and run our business operations. For exampe: Treatment. We may discose your heath information to a heath care provider that provides treatment to you. We may use your information to notify a physician who treats you of the prescription drugs you are taking. Payment. We wi use your heath information to obtain premium payments, speciaty pharmacy payments, or to fufi our responsibiity for coverage and the provision of benefits under a heath pan, such as processing a physician caim for reimbursement for services provided to you. Heath Care Operations. We may aso discose your heath information in connection with our heath care operations. These incude fraud, waste and abuse detection and compiance programs, customer service and resoution of interna grievances. Treatment Aternatives and Heath-Reated Benefits and Services. We may use and discose your heath information to te you about treatment options or aternatives, appointment reminders, and heath-reated benefits or services that may be of interest to you. Underwriting. We may use or discose your heath information for certain underwriting purposes. However, we wi not use or discose your genetic information for underwriting purposes. Famiy Members, Reatives or Cose Friends Invoved in Your Care. Uness you object, we may discose your heath information to your famiy members, reatives or cose persona friends identified by you as being invoved in your treatment or payment for your medica care. If you are not present to agree or object, we may exercise our professiona judgment to determine whether the discosure is in your best interest. If we decide to discose your heath information to your famiy member, reative or other individua identified by you, we wi ony discose the heath information that is reevant to your treatment or payment. Business Associates. We may discose your heath information to a business associate that needs the information in order to perform a function or service for our business operations. We wi do so ony if the business associate signs an agreement to protect the privacy of your heath information. Third party administrators, auditors, awyers, and consutants are some exampes of business associates.

106 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities Pubic Need. We may use your heath information, and share it with others, in order to compy with the aw or to meet important pubic needs that are described beow: if we are required by aw to do so; to authorized pubic heath officias (or a foreign government agency coaborating with such officias) so they may carry out their pubic heath activities; to government agencies authorized to conduct audits, investigations, and inspections, as we as civi, administrative or crimina investigations, proceedings, or actions, incuding those agencies that monitor programs such as Medicare and Medicaid; to a pubic heath authority if we reasonaby beieve you are a possibe victim of abuse, negect or domestic vioence; to a person or company that is reguated by the Food and Drug Administration for: (i) reporting or tracking product defects or probems, (ii) repairing, repacing, or recaing defective or dangerous products, or (iii) monitoring the performance of a product after it has been approved for use by the genera pubic; if ordered by a court or administrative tribuna to do so, or pursuant to a subpoena, discovery or other awfu request by someone ese invoved in the dispute, but ony if efforts have been made to te you about the request or to obtain a court order protecting the information from further discosure; to aw enforcement officias to compy with court orders or aws, and to assist aw enforcement officers with identifying or ocating a suspect, fugitive, witness, or missing person; to prevent a serious and imminent threat to your heath or safety, or the heath or safety of another person or the pubic, which we wi ony share with someone abe to hep prevent the threat; for research purposes; to the extent necessary to compy with workers' compensation or other programs estabished by aw that provide benefits for work-reated injuries or iness without regard to fraud; to appropriate miitary command authorities for activities they deem necessary to carry out their miitary mission; to authorized federa officias who are conducting nationa security and inteigence activities or providing protective services to the President or other important officias; to the prison officers or aw enforcement officers if necessary to provide you with heath care, or to maintain safety, security and good order at the pace where you are confined; in the unfortunate event of your death, to a coroner or medica examiner, for exampe, to determine the cause of death; to funera directors as necessary to carry out their duties; and in the unfortunate event of your death, to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transpantation is possibe under aw.

107 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities Competey De-Identified and Partiay De-Identified Information. We may use and discose competey de-identified heath information about you if we have removed any information that has the potentia to identify you. We may aso use and discose partiay de-identified heath information about you for pubic heath and research purposes, or for business operations, if the person who wi receive the information signs an agreement to protect the privacy of the information as required by federa and state aw. Partiay de-identified heath information wi not contain any information that woud directy identify you (such as your name, street address, Socia Security number, phone number, fax number, eectronic mai address, Web site address, or icense number). Requirement for Written Authorization We may use your heath information for treatment, payment, heath care operations or other purposes described in this Privacy Notice. You may aso give us written authorization to use your heath information or to discose it to anyone for any purpose. We cannot use or discose your heath information for any reason, except those described in this Privacy Notice, uness you give us a written authorization to do so. For exampe, we require your written authorization for most uses and discosures of psychotherapy notes (where appropriate), uses and discosures of heath information for marketing purposes, and discosures that constitute a sae of your heath information. Marketing is a communication about a product or service that encourages recipients of the communication to purchase or use the product or service. You may revoke your authorization in writing at any time. Your revocation wi not affect any use or discosures permitted by your authorization whie it was in effect.

108 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 103 Your Rights to Access and Contro Your Heath Information We want you to know that you have the foowing rights to access and contro your heath information. 1. Right to Access Your Heath Information. You have the right t 〇 inspect and obtain a copy of your heath information except for heath information: (i) contained in psychotherapy notes; (ii) compied in anticipation of, or for use in, a civi, crimina, or administrative proceeding; and (iii) with some exceptions, information subject to the Cinica Laboratory Improvements Amendments of 1988 (CLIA). If we use or maintain an eectronic heath record (EHR) for you, you have the right to obtain a copy of your EHR in eectronic format. You aso have the right to direct us to send a copy of your EHR to a third party that you ceary designate. If you woud ike to access your heath information, pease send your written request to the address isted on the ast page of this Privacy Notice. We wi ordinariy respond to your request within 30 days if the information is ocated in our faciity, and within 60 days if it is ocated off-site at another faciity. If we need additiona time to respond, we wi et you know as soon as possibe. We may charge you a reasonabe, cost-based fee to cover copy costs and postage. If you request a copy of your EHR, we wi not charge you any more than our abor costs in producing the EHR to you. We may not give you access to your heath information if it: (i) is reasonaby ikey to endanger the ife and physica safety of you or someone ese as determined by a icensed heath care professiona; (ii) refers to another person and a icensed heath care professiona determines that your access is ikey to cause harm to that person; or (iii) a icensed heath care professiona determines that your access as the representative of another person is ikey to cause harm to that person or any other person. If you are denied access for one of these reasons, you are entited to a review by a heath care professiona, designated by us, who was not invoved in the decision to deny access. If access is utimatey denied, you wi be entited to a written expanation of the reasons for the denia. 2. Right to Amend Your Heath Information. If you beieve we have heath information about you that is incorrect or incompete, you may request in writing an amendment to your heath information. If we do not have your heath information, we wi give you the contact information of someone who does. You wi receive a response within 60 days after we receive your request. If we did not create your heath information or your heath information is aready accurate and compete, we can deny your request and notify you of our decision in writing. You can aso submit a statement that you disagree with our decision, which we can rebut. You have the right to request that your origina request, our denia, your statement of disagreement, and our rebutta be incuded in future discosures of your heath information.

109 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities Right to Receive an Accounting of Discosures. You have the right t 〇 receive a 门 accounting of discosures of your heath information made by us and our business associates. You may request such information for the six-year period prior to the date of your request. Accounting of discosures wi not incude discosures: (i) for payment, treatment or heath care operations; (ii) made to you or your persona representative; (iii) that you authorized in writing; (iv) made to famiy and friends invoved in your care or payment for your care; (v) for research, pubic heath or our business operations; (vi) made to federa officias for nationa security and inteigence activities; (vii) made to correctiona institutions or aw enforcement; and (viii) of an incident reated to a use or discosure otherwise permitted or required by aw. If you woud ike to receive an accounting of discosures, pease write to the address isted on the ast page of this Privacy Notice. If we do not have your heath information, we wi give you the contact information of someone who does. You wi receive a response within 60 days after your request is received. You wi receive one request annuay free of charge, but we may charge you a reasonabe, cost-based fee for additiona requests within the same tweve-month period. 4. Right to Request Additiona Privacy Protections. You have the right t 〇 request that we pace additiona restrictions on our use or discosure of your heath information. If we agree to do so, we wi put these restrictions in pace except in an emergency situation. We do not need to agree to the restriction uness (i) the discosure is for the purpose of carrying out payment or heath care operations and is not otherwise required by aw, and (ii) the heath information reates ony to a heath care item or service that you or someone on your behaf has paid for out of pocket and in fu. You have the right to revoke the restriction at any time. 5. Right to Request Confiden 廿 a Communications. You have the right t 〇 request that we communicate with you about your heath information by aternative means or via aternative ocations. If you wish to receive confidentia communications via aternative means or ocations, pease submit your written request to the address isted on the ast page of this Privacy Notice. You must ceary state in your request that the discosure of your heath information coud endanger you and ist how or where you wish to receive communications.

110 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities Right to Notice of Breach of Unencrypted Heath Information. We are required by aw to maintain the privacy of your heath information, and to provide you with this Privacy Notice containing our ega duties and privacy practices with respect to your protected heath information. Our poicy is to encrypt our eectronic fies containing your heath information so as to protect the information from those who shoud not have access to it. If, however, for some reason we experience a breach of your unencrypted heath information, we wi notify you of the breach. If we have more than ten peope that we cannot reach because of outdated contact information, we wi post a notification either on our Web site ( or in a major media outet in your area. 7. Right to Obtain a Paper Copy of this Notice. You have the right at any time to obtain a paper copy of this Privacy Notice, even if you receive this Privacy Notice eectronicay. Pease send your written request to the address isted on this page of this Privacy Notice or visit our Web site at Misceaneous 1. Contact Information. If you have any questions about this Privacy Notice, you may contact the Privacy Officer at (TTY/TDD ), ca the to-free number isted on the back of your membership card, visit or write to us at: WeCare Heath Pans, Inc. Attention: Privacy Officer P.O. Box Tampa, FL Compaints. If you are concerned that we may have vioated your privacy rights, you may compain to us using the contact information above. You aso may submit a written compaint to the U.S. Department of Heath and Human Services. If you choose to fie a compaint, we wi not retaiate or take action against you for your compaint. 3. Additiona Rights. This Privacy Notice expains the rights you have with respect to your heath information, incuding access and amendment rights, under federa aw. Some state aws provide even greater rights, incuding more favorabe access and amendment rights, as we as more protection for particuary sensitive information, such as information invoving HIV/AIDS, menta heath, acoho and drug abuse, sexuay transmitted diseases, and reproductive heath. To the extent the aw in the state where you reside affords you greater rights than described in this Privacy Notice, we wi compy with these aws.

111 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 106 Section 1.5 We must give you information about the pan, its network of pharmacies, and your covered drugs As a member of our pan, you have the right to get severa kinds of information from us. (As expained above in Section 1.1, you have the right to get information from us in a way that works for you. This incudes getting the information in anguages other than Engish and in Braie or other aternate formats.) If you want any of the foowing kinds of information, pease ca Customer Service (phone numbers are printed on the back cover of this booket): Information about our pan. This incudes, for exampe, information about the pan s financia condition. It aso incudes information about the number of appeas made by members and the pan s performance ratings, incuding how it has been rated by pan members and how it compares to other Medicare prescription drug pans. Information about our network pharmacies. For exampe, you have the right to get information from us about the pharmacies in our network. For a ist of the pharmacies in the pan s network, see the Pharmacy Directory. For more detaied information about our pharmacies, you can ca Customer Service (phone numbers are printed on the back cover of this booket) or visit our website at Information about your coverage and the rues you must foow when using your coverage. To get the detais on your Part D prescription drug coverage, see Chapters 3 and 4 of this booket pus the pan s List of Covered Drugs (Formuary). These chapters, together with the List of Covered Drugs (Formuary), te you what drugs are covered and expain the rues you must foow and the restrictions to your coverage for certain drugs. If you have questions about the rues or restrictions, pease ca Customer Service (phone numbers are printed on the back cover of this booket). Information about why something is not covered and what you can do about it.

112 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 107 If a Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written expanation. You have the right to this expanation even if you received the drug from an out-of-network pharmacy. If you are not happy or if you disagree with a decision we make about what Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appea. For detais on what to do if something is not covered for you in the way you think it shoud be covered, see Chapter 7 of this booket. It gives you the detais about how to make an appea if you want us to change our decision. (Chapter 7 aso tes about how to make a compaint about quaity of care, waiting times, and other concerns.) If you want to ask our pan to pay our share of the cost for a Part D prescription drug, see Chapter 5 of this booket. Section 1.6 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 abe to make medica decisions for yoursef Sometimes peope become unabe to make heath care decisions for themseves due to accidents or serious iness. 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: Fi out a written form to give someone the ega authority to make medica decisions for you if you ever become unabe to make decisions for yoursef. Give your doctors written instructions about how you want them to hande your medica care if you become unabe to make decisions for yoursef. The ega documents that you can use to give your directions in advance in these situations are caed advance directives. There are different types of advance directives and different names for them. Documents caed iving wi and power of attorney for heath care are exampes of advance directives. If you want to use an advance directive to give your instructions, here is what to do: Get the form. If you want to have an advance directive, you can get a form from your awyer, from a socia worker, or from some office suppy stores. You can sometimes get advance directive forms from organizations that give peope information about Medicare.

113 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 108 Fi it out and sign it. Regardess of where you get this form, keep in mind that it is a ega document. You shoud consider having a awyer hep you prepare it. Give copies to appropriate peope. You shoud give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can t. You may want to give copies to cose friends or famiy members as we. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitaized, and you have signed an advance directive, take a copy with you to the hospita. If you are admitted to the hospita, they wi 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 hospita has forms avaiabe and wi ask if you want to sign one. Remember, it is your choice whether you want to fi out an advance directive (incuding whether you want to sign one if you are in the hospita). According to aw, 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 foowed? If you have signed an advance directive, and you beieve that a doctor or hospita did not foow the instructions in it, you may fie a compaint with the state agency isted beow. State Aabama Arkansas Idaho Louisiana Mississippi Missouri Okahoma Oregon State Agency for Advance Directive Compaints Aabama Department of Pubic Heath Arkansas Department of Heath Idaho Department of Heath and Wefare Louisiana Department Heath and Hospitas, Office of Pubic Heath Mississippi Department of Heath Missouri Department of Heath Okahoma State Department of Heath Oregon Department of Human Resources

114 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 109 State South Caroina Tennessee Texas Utah Virginia Washington State Agency for Advance Directive Compaints South Caroina Department of Heath and Environmenta Contro Tennessee Department of Heath Texas Department of Heath Utah Department of Heath Virginia Department of Heath Washington State Department of Heath Section 1.7 You have the right to make compaints and to ask us to reconsider decisions we have made If you have any probems or concerns about your covered services or care, Chapter 7 of this booket tes what you can do. It gives the detais about how to dea with a types of probems and compaints. As expained in Chapter 7, what you need to do to foow up on a probem or concern depends on the situation. You might need to ask our pan to make a coverage decision for you, make an appea to us to change a coverage decision, or make a compaint. Whatever you do ask for a coverage decision, make an appea, or make a compaint we are required to treat you fairy. You have the right to get a summary of information about the appeas and compaints that other members have fied against our pan in the past. To get this information, pease ca Customer Service (phone numbers are printed on the back cover of this booket). Section 1.8 What can you do if you beieve you are being treated unfairy or your rights are not being respected? If it is about discrimination, ca the Office for Civi Rights If you beieve you have been treated unfairy or your rights have not been respected due to your race, disabiity, reigion, sex, heath, ethnicity, creed (beiefs), age, or nationa origin, you shoud ca the Department of Heath and Human Services Office for Civi Rights at or TTY , or ca your oca Office for Civi Rights.

115 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 110 Is it about something ese? If you beieve you have been treated unfairy or your rights have not been respected, and it s not about discrimination, you can get hep deaing with the probem you are having: You can ca Customer Service (phone numbers are printed on the back cover of this booket). You can ca the State Heath Insurance Assistance Program. For detais about this organization and how to contact it, go to Chapter 2, Section 3. Or, you can ca Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca Section 1.9 How to get more information about your rights There are severa paces where you can get more information about your rights: You can ca Customer Service (phone numbers are printed on the back cover of this booket). You can ca the State Heath Insurance Assistance Program. For detais about this organization and how to contact it, go to Chapter 2, Section 3. You can contact Medicare. You can visit the Medicare website to read or downoad the pubication Your Medicare Rights & Protections. (The pubication is avaiabe at: Or, you can ca MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca SECTION 2 Section 2.1 You have some responsibiities as a member of the pan What are your responsibiities? Things you need to do as a member of the pan are isted beow. If you have any questions, pease ca Customer Service (phone numbers are printed on the back cover of this booket). We re here to hep.

116 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 111 Get famiiar with your covered drugs and the rues you must foow to get these covered drugs. Use this Evidence of Coverage booket to earn what is covered for you and the rues you need to foow to get your covered drugs. Chapters 3 and 4 give the detais about your coverage for Part D prescription drugs. If you have any other prescription drug coverage in addition to our pan, you are required to te us. Pease ca Customer Service to et us know (phone numbers are printed on the back cover of this booket). We are required to foow rues set by Medicare to make sure that you are using a of your coverage in combination when you get your covered drugs from our pan. This is caed coordination of benefits because it invoves coordinating the drug benefits you get from our pan with any other drug benefits avaiabe to you. We hep you coordinate your benefits. (For more information about coordination of benefits, go to Chapter 1, Section 7.) Te your doctor and pharmacist that you are enroed in our pan. Show your pan membership card whenever you get your Part D prescription drugs. Hep your doctors and other providers hep you by giving them information, asking questions, and foowing through on your care. To hep your doctors and other heath providers give you the best care, earn as much as you are abe to about your heath probems and give them the information they need about you and your heath. Foow the treatment pans and instructions that you and your doctors agree upon. Make sure your doctors know a of the drugs you are taking, incuding over-the-counter drugs, vitamins, and suppements. If you have any questions, be sure to ask. Your doctors and other heath care providers are supposed to expain things in a way you can understand. If you ask a question and you don t understand the answer you are given, ask again. Pay what you owe. As a pan member, you are responsibe for these payments: You must pay your pan premiums to continue being a member of our pan. For most of your drugs covered by the pan, you must pay your share of the cost when you get the drug. This wi be a co-payment (a fixed

117 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 6: Your rights and responsibiities 112 amount) or coinsurance (a percentage of the tota cost) Chapter 4 tes what you must pay for your Part D prescription drugs. If you get any drugs that are not covered by our pan or by other insurance you may have, you must pay the fu cost. u If you disagree with our decision to deny coverage for a drug, you can make an appea. Pease see Chapter 7 of this booket for information about how to make an appea. If you are required to pay a ate enroment penaty, you must pay the penaty to remain a member of the pan. If you are required to pay the extra amount for Part D because of your yeary income, you must pay the extra amount directy to the government to remain a member of the pan. Te us if you move. If you are going to move, it s important to te us right away. Ca Customer Service (phone numbers are printed on the back cover of this booket). If you move outside of our pan service area, you cannot remain a member of our pan. (Chapter 1 tes about our service area.) We can hep you figure out whether you are moving outside our service area. If you are eaving our service area, you wi have a Specia Enroment Period when you can join any Medicare pan avaiabe in your new area. We can et you know if we have a pan in your new area. If you move within our service area, we sti need to know so we can keep your membership record up to date and know how to contact you. If you move, it is aso important to te Socia Security (or the Rairoad Retirement Board). You can find phone numbers and contact information for these organizations in Chapter 2. Ca Customer Service for hep if you have questions or concerns. We aso wecome any suggestions you may have for improving our pan. Phone numbers and caing hours for Customer Service are printed on the back cover of this booket. For more information on how to reach us, incuding our maiing address, pease see Chapter 2.

118 2015 Evidence of Coverage for WeCare Simpe (PDP) 113 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Chapter 7. What to do if you have a probem or compaint (coverage decisions, appeas, compaints) BACKGROUND SECTION 1 Introduction Section 1.1 What to do if you have a probem or concern Section 1.2 What about the ega terms? SECTION 2 You can get hep from government organizations that are not connected with us Section 2.1 Where to get more information and personaized assistance SECTION 3 To dea with your probem, which process shoud you use?. 116 Section 3.1 Shoud you use the process for coverage decisions and appeas? Or shoud you use the process for making compaints? COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeas Section 4.1 Asking for coverage decisions and making appeas: the big picture Section 4.2 How to get hep when you are asking for a coverage decision or making an appea SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appea Section 5.1 This section tes you what to do if you have probems getting a Part D drug or you want us to pay you back for a Part D drug Section 5.2 What is an exception? Section 5.3 Important things to know about asking for exceptions Section 5.4 Step-by-step: How to ask for a coverage decision, incuding an exception Section 5.5 Step-by-step: How to make a Leve 1 Appea (how to ask for a review of a coverage decision made by our pan)

119 2015 Evidence of Coverage for WeCare Simpe (PDP) 114 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Section 5.6 Step-by-step: How to make a Leve 2 Appea SECTION 6 Taking your appea to Leve 3 and beyond Section 6.1 Leves of Appea 3, 4, and 5 for Part D Drug Appeas MAKING COMPLAINTS SECTION 7 How to make a compaint about quaity of care, waiting times, customer service, or other concerns Section 7.1 What kinds of probems are handed by the compaint process? Section 7.2 The forma name for making a compaint is fiing a grievance Section 7.3 Step-by-step: Making a compaint Section 7.4 You can aso make compaints about quaity of care to the Quaity Improvement Organization Section 7.5 You can aso te Medicare about your compaint

120 2015 Evidence of Coverage for WeCare Simpe (PDP) 115 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) BACKGROUND SECTION 1 Section 1.1 Introduction What to do if you have a probem or concern This chapter expains two types of processes for handing probems and concerns: For some types of probems, you need to use the process for coverage decisions and appeas. For other types of probems you need to use the process for making compaints. Both of these processes have been approved by Medicare. To ensure fairness and prompt handing of your probems, each process has a set of rues, procedures, and deadines that must be foowed by us and by you. Which one do you use? That depends on the type of probem you are having. The guide in Section 3 wi hep you identify the right process to use. Section 1.2 What about the ega terms? There are technica ega terms for some of the rues, procedures, and types of deadines expained in this chapter. Many of these terms are unfamiiar to most peope and can be hard to understand. To keep things simpe, this chapter expains the ega rues and procedures using simper words in pace of certain ega terms. For exampe, this chapter generay says making a compaint rather than fiing a grievance, coverage decision rather than coverage determination, and Independent Review Organization instead of Independent Review Entity. It aso uses abbreviations as itte as possibe. However, it can be hepfu - and sometimes quite important - for you to know the correct ega terms for the situation you are in. Knowing which terms to use wi hep you communicate more ceary and accuratey when you are deaing with your probem and get the right hep or information for your situation. To hep you know which terms to use, we incude ega terms when we give the detais for handing specific types of situations.

121 2015 Evidence of Coverage for WeCare Simpe (PDP) 116 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) SECTION 2 You can get hep from government organizations that are not connected with us Section 2.1 Where to get more information and personaized assistance Sometimes it can be confusing to start or foow through the process for deaing with a probem. This can be especiay true if you do not fee we or have imited energy. Other times, you may not have the knowedge you need to take the next step. Get hep from an independent government organization We are aways avaiabe to hep you. But in some situations you may aso want hep or guidance from someone who is not connected us. You can aways contact your State Heath Insurance Assistance Program (SHIP). This government program has trained counseors in every state. The program is not connected with us or with any insurance company or heath pan. The counseors at this program can hep you understand which process you shoud use to hande a probem you are having. They can aso answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counseors are free. You wi find phone numbers in the appendix at the back of this booket. You can aso get hep and information from Medicare For more information and hep in handing a probem, you can aso contact Medicare. Here are two ways to get information directy from Medicare: You can ca MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca You can visit the Medicare website ( SECTION 3 Section 3.1 To dea with your probem, which process shoud you use? Shoud you use the process for coverage decisions and appeas? Or shoud you use the process for making compaints? If you have a probem or concern, you ony need to read the parts of this chapter that appy to your situation. The guide that foows wi hep.

122 2015 Evidence of Coverage for WeCare Simpe (PDP) 117 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) To figure out which part of this chapter wi hep with your specific probem or concern, START HERE Is your probem or concern about your benefits or coverage? (This incudes probems about whether particuar medica care or prescription drugs are covered or not, the way in which they are covered, and probems reated to payment for medica care or prescription drugs.) Yes. My probem is about benefits or coverage. Go on to the next section of this chapter, Section 4, A guide to the basics of coverage decisions and appeas. No. My probem is not about benefits or coverage. Skip ahead to Section 7 at the end of this chapter: How to make a compaint about quaity of care, waiting times, customer service or other concerns. COVERAGE DECISIONS AND APPEALS SECTION 4 Section 4.1 A guide to the basics of coverage decisions and appeas Asking for coverage decisions and making appeas: the big picture The process for coverage decisions and appeas deas with probems reated to your benefits and coverage for prescription drugs, incuding probems reated to payment. 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 A coverage decision is a decision we make about your benefits and coverage or about the amount we wi 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 onger covered by Medicare for you. If you disagree with this coverage decision, you can make an appea. Making an appea

123 2015 Evidence of Coverage for WeCare Simpe (PDP) 118 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If we make a coverage decision and you are not satisfied with this decision, you can appea the decision. An appea is a forma way of asking us to review and change a coverage decision we have made. When you make an appea, we review the coverage decision we have made to check to see if we were foowing a of the rues propery. Your appea is handed by different reviewers than those who made the origina unfavorabe decision. When we have competed the review we give you our decision. If we say no to a or part of your Leve 1 Appea, you can ask for a Leve 2 Appea. The Leve 2 Appea is conducted by an independent organization that is not connected to us. If you are not satisfied with the decision at the Leve 2 Appea, you may be abe to continue through additiona eves of appea. Section 4.2 How to get hep when you are asking for a coverage decision or making an appea Woud you ike some hep? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appea a decision: You can ca us at Customer Service (phone numbers are printed on the back cover of this booket). To get free hep from an independent organization that is not connected with our pan, contact your State Heath Insurance Assistance Program (see Section 2 of this chapter). 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 Leve 1 or Leve 2 Appea on your behaf. To request any appea after Leve 2, your doctor or other prescriber must be appointed as your representative. You can ask someone to act on your behaf. 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 appea. There may be someone who is aready egay authorized to act as your representative under State aw. If you want a friend, reative, your doctor or other prescriber, or other person to be your representative, ca Customer Service (phone numbers are printed on the back cover of this booket) and ask for the Appointment of

124 2015 Evidence of Coverage for WeCare Simpe (PDP) 119 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Representative form. (The form is aso avaiabe on Medicare s website at or on our website at The form gives that person permission to act on your behaf. It must be signed by you and by the person who you woud ike to act on your behaf. You must give us a copy of the signed form. You aso have the right to hire a awyer to act for you. You may contact your own awyer, or get the name of a awyer from your oca bar association or other referra service. There are aso groups that wi give you free ega services if you quaify. However, you are not required to hire a awyer to ask for any kind of coverage decision or appea a decision. SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appea? Have you read Section 4 of this chapter (A guide to the basics of coverage decisions and appeas)? If not, you may want to read it before you start this section. Section 5.1 This section tes you what to do if you have probems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits as a member of our pan incude coverage for many prescription drugs. Pease refer to our pan s List of Covered Drugs (Formuary). To be covered, the drug must be used for a medicay accepted indication. (A medicay 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 Chapter 3, Section 3 for more information about a medicay accepted indication.) This section is about your Part D drugs ony. To keep things simpe, we generay say drug in the rest of this section, instead of repeating covered outpatient prescription drug or Part D drug every time. For detais about what we mean by Part D drugs, the List of Covered Drugs (Formuary), rues and restrictions on coverage, and cost information, see Chapter 3 (Using our pan s coverage for your Part D prescription drugs) and Chapter 4 (What you pay for your Part D prescription drugs).

125 2015 Evidence of Coverage for WeCare Simpe (PDP) 120 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Part D coverage decisions and appeas As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we wi pay for your drugs. Lega Terms An initia coverage decision about your Part D drugs is caed a coverage determination. Here are exampes of coverage decisions you ask us to make about your Part D drugs: You ask us to make an exception, incuding: Asking us to cover a Part D drug that is not on the pan s List of Covered Drugs (Formuary) Asking us to waive a restriction on the pan s coverage for a drug (such as imits on the amount of the drug you can get) Asking to pay a ower cost-sharing amount for a covered non-preferred drug You ask us whether a drug is covered for you and whether you satisfy any appicabe coverage rues. (For exampe, when your drug is on the pan s List of Covered Drugs (Formuary) but we require you to get approva from us before we wi cover it for you.) Pease note: If your pharmacy tes you that your prescription cannot be fied as written, you wi get a written notice expaining how to contact us to ask for a coverage decision. You ask us to pay for a prescription drug you aready bought. This is a request for a coverage decision about payment. If you disagree with a coverage decision we have made, you can appea our decision. This section tes you both how to ask for coverage decisions and how to request an appea. Use the chart beow to hep you determine which part has information for your situation: Which of these situations are you in?

126 2015 Evidence of Coverage for WeCare Simpe (PDP) 121 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If you are in this situation: Do you need a drug that isn t on our Drug List or need us to waive a rue or restriction on a drug we cover? Do you want us to cover a drug on our Drug List and you beieve you meet any pan rues or restrictions (such as getting approva in advance) for the drug you need? Do you want to ask us to pay you back for a drug you have aready received and paid for? Have we aready tod you that we wi not cover or pay for a drug in the way that you want it to be covered or paid for? This is what you can do: You can ask us to make an exception. (This is a type of coverage decision.) Start with Section 5.2 of this chapter You can ask us for a coverage decision. Skip ahead to Section 5.4 of this chapter. You can ask us to pay you back. (This is a type of coverage decision.) Skip ahead to Section 5.4 of this chapter. You can make an appea. (This means you are asking us to reconsider.) Skip ahead to Section 5.5 of this chapter. Section 5.2 What is an exception? If a drug is not covered in the way you woud ike it to be covered, you can ask us to make an exception. An exception is a type of coverage decision. Simiar to other types of coverage decisions, if we turn down your request for an exception, you can appea our decision. When you ask for an exception, your doctor or other prescriber wi need to expain the medica reasons why you need the exception approved. We wi then consider your request. Here are three exampes 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 List of Covered Drugs (Formuary). (We ca it the Drug List for short.) Lega Terms Asking for coverage of a drug that is not on the Drug List is sometimes caed asking for a formuary exception.

127 2015 Evidence of Coverage for WeCare Simpe (PDP) 122 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If we agree to make an exception and cover a drug that is not on the Drug List, you wi need to pay the cost-sharing amount that appies to drugs in tier 4. You cannot ask for an exception to the co-payment or coinsurance amount we require you to pay for the drug. 2. Removing a restriction on our coverage for a covered drug. There are extra rues or restrictions that appy to certain drugs on our List of Covered Drugs (Formuary) (for more information, go to Chapter 3). Lega Terms Asking for remova of a restriction on coverage for a drug is sometimes caed asking for a formuary exception. The extra rues and restrictions on coverage for certain drugs incude: Being required to use the generic version of a drug instead of the brand name drug. Getting pan approva in advance before we wi agree to cover the drug for you. (This is sometimes caed prior authorization. ) Being required to try a different drug first before we wi agree to cover the drug you are asking for. (This is sometimes caed step therapy. ) Quantity imits. For some drugs, there are restrictions on the amount of the drug you can have. If we agree to make an exception and waive a restriction for you, you can ask for an exception to the co-payment or coinsurance amount we require you to pay for the drug. 3. Changing coverage of a drug to a ower cost-sharing tier. Every drug on our Drug List is in one of five cost-sharing tiers. In genera, the ower the cost-sharing tier number, the ess you wi pay as your share of the cost of the drug. Lega Terms Asking to pay a ower preferred price for a covered non-preferred drug is sometimes caed asking for a tiering exception.

128 2015 Evidence of Coverage for WeCare Simpe (PDP) 123 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If your drug is in Tier 2 (Non-Preferred Generic Drugs) you can ask us to cover it at the cost-sharing amount that appies to drugs in Tier 1 (Preferred Generic Drugs). This woud ower your share of the cost for the drug. If your drug is in Tier 4 (Non-Preferred Brand Drugs) you can ask us to cover it at the cost-sharing amount that appies to drugs in Tier 3 (Preferred Brand Drugs). This woud ower your share of the cost for the drug. You cannot ask us to change the cost-sharing tier for any drug in Tier 1 (Preferred Generic Drugs), Tier 3 (Preferred Brand Drugs) or Tier 5 (Speciaty Tier Drugs). Section 5.3 Important things to know about asking for exceptions Your doctor must te us the medica reasons Your doctor or other prescriber must give us a statement that expains the medica reasons for requesting an exception. For a faster decision, incude this medica information from your doctor or other prescriber when you ask for the exception. Typicay, our Drug List incudes more than one drug for treating a particuar condition. These different possibiities are caed aternative drugs. If an aternative drug woud be just as effective as the drug you are requesting and woud not cause more side effects or other heath probems, we wi generay not approve your request for an exception. We can say yes or no to your request If we approve your request for an exception, our approva usuay is vaid unti the end of the pan year. This is true as ong 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 for an exception, you can ask for a review of our decision by making an appea. Section 5.5 tes you how to make an appea if we say no. The next section tes you how to ask for a coverage decision, incuding an exception.

129 2015 Evidence of Coverage for WeCare Simpe (PDP) 124 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Section 5.4 Step-by-step: How to ask for a coverage decision, incuding an exception Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your heath requires a quick response, you must ask us to make a fast coverage decision. You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you aready bought. What to do Request the type of coverage decision you want. Start by caing, writing, or faxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can aso access the coverage decision process through our website. For the detais, go to Chapter 2, Section 1 and ook for the section caed, How to contact us when you are asking for a coverage decision about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section caed, Where to send a request that asks us to pay for our share of the cost for a drug you have received. You or your doctor or someone ese who is acting on your behaf can ask for a coverage decision. Section 4 of this chapter tes how you can give written permission to someone ese to act as your representative. You can aso have a awyer act on your behaf. If you want to ask us to pay you back for a drug, start by reading Chapter 5 of this booket: Asking us to pay our share of the costs for covered drugs. Chapter 5 describes the situations in which you may need to ask for reimbursement. It aso tes how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for. If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medica reasons for the drug exception you are requesting. (We ca this the supporting statement. ) Your doctor or other prescriber can fax or mai the statement to us. Or your doctor or other prescriber can te us on the phone and foow up by faxing or maiing a written statement if necessary. See Sections 5.2 and 5.3 for more information about exception requests.

130 2015 Evidence of Coverage for WeCare Simpe (PDP) 125 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) We must accept any written request, incuding a request submitted on the CMS Mode Coverage Determination Request Form, which is avaiabe on our website. If your heath requires it, ask us to give you a fast coverage decision Lega Terms A fast coverage decision is caed an expedited coverage determination. When we give you our decision, we wi use the standard deadines uness we have agreed to use the fast deadines. A standard coverage decision means we wi give you an answer within 72 hours after we receive your doctor s statement. A fast coverage decision means we wi answer within 24 hours. To get a fast coverage decision, you must meet two requirements: You can get a fast coverage decision ony if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have aready bought.) You can get a fast coverage decision ony if using the standard deadines coud cause serious harm to your heath or hurt your abiity to function. If your doctor or other prescriber tes us that your heath requires a fast coverage decision, we wi automaticay agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own (without your doctor s or other prescriber s support), we wi decide whether your heath requires that we give you a fast coverage decision. If we decide that your medica condition does not meet the requirements for a fast coverage decision, we wi send you a etter that says so (and we wi use the standard deadines instead). This etter wi te you that if your doctor or other prescriber asks for the fast coverage decision, we wi automaticay give a fast coverage decision. The etter wi aso te how you can fie a compaint about our decision to give you a standard coverage decision instead of the fast coverage

131 2015 Evidence of Coverage for WeCare Simpe (PDP) 126 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) decision you requested. It tes how to fie a fast compaint, which means you woud get our answer to your compaint within 24 hours. (The process for making a compaint is different from the process for coverage decisions and appeas. For more information about the process for making compaints, see Section 7 of this chapter.) Step 2: We consider your request and we give you our answer. Deadines for a fast coverage decision If we are using the fast deadines, we must give you our answer within 24 hours. Generay, this means within 24 hours after we receive your request. If you are requesting an exception, we wi give you our answer within 24 hours after we receive your doctor s statement supporting your request. We wi give you our answer sooner if your heath requires us to. If we do not meet this deadine, we are required to send your request on to Leve 2 of the appeas process, where it wi be reviewed by an independent organization. Later in this section, we te about this review organization and expain what happens at Appea Leve 2. If our answer is yes to part or a 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 a of what you requested, we wi send you a written statement that expains why we said no. We wi aso te you how to appea. Deadines for a standard coverage decision about a drug you have not yet received If we are using the standard deadines, we must give you our answer within 72 hours. Generay, this means within 72 hours after we receive your request. If you are requesting an exception, we wi give you our answer within 72 hours after we receive your doctor s statement supporting your request. We wi give you our answer sooner if your heath requires us to. If we do not meet this deadine, we are required to send your request on to Leve 2 of the appeas process, where it wi be reviewed by an independent organization. Later in this section, we te about this review organization and expain what happens at Appea Leve 2.

132 2015 Evidence of Coverage for WeCare Simpe (PDP) 127 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If our answer is yes to part or a of what you requested If we approve your request for coverage, 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 a of what you requested, we wi send you a written statement that expains why we said no. We wi aso te you how to appea. Deadines for a standard coverage decision about payment for a drug you have aready bought We must give you our answer within 14 caendar days after we receive your request. If we do not meet this deadine, we are required to send your request on to Leve 2 of the appeas process, where it wi be reviewed by an independent organization. Later in this section, we te about this review organization and expain what happens at Appea Leve 2. If our answer is yes to part or a of what you requested, we are aso required to make payment to you within 14 caendar days after we receive your request. If our answer is no to part or a of what you requested, we wi send you a written statement that expains why we said no. We wi aso te you how to appea. Step 3: If we say no to your coverage request, you decide if you want to make an appea. If we say no, you have the right to request an appea. Requesting an appea means asking us to reconsider - and possiby change - the decision we made. Section 5.5 Step-by-step: How to make a Leve 1 Appea (how to ask for a review of a coverage decision made by our pan) Lega Terms An appea to the pan about a Part D drug coverage decision is caed a pan redetermination.

133 2015 Evidence of Coverage for WeCare Simpe (PDP) 128 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Step 1: You contact us and make your Leve 1 Appea. If your heath requires a quick response, you must ask for a fast appea. What to do To start your appea, you (or your representative or your doctor or other prescriber) must contact us. For detais on how to reach us by phone, fax,mai, or on our website, for any purpose reated to your appea, go to Chapter 2, Section 1, and ook for the section caed, How to contact our pan when you are making an appea about your Part D prescription drugs. If you are asking for a standard appea, make your appea by submitting a written request. If you are asking for a fast appea, you may make your appea in writing or you may ca us at the phone number shown in Chapter 2, Section 1 (How to contact our pan when you are making an appea about your part D prescription drugs). We must accept any written request, incuding a request submitted on the CMS Mode Coverage Determination Request Form, which is avaiabe on our website. You must make your appea request within 60 caendar days from the date on the written notice we sent to te you our answer to your request for a coverage decision. If you miss this deadine and have a good reason for missing it, we may give you more time to make your appea. Exampes of good cause for missing the deadine may incude if you had a serious iness that prevented you from contacting us or if we provided you with incorrect or incompete information about the deadine for requesting an appea. You can ask for a copy of the information in your appea and add more information. You have the right to ask us for a copy of the information regarding your appea. If you wish, you and your doctor or other prescriber may give us additiona information to support your appea. If your heath requires it, ask for a fast appea

134 2015 Evidence of Coverage for WeCare Simpe (PDP) 129 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Lega Terms A fast appea is aso caed an expedited redetermination. If you are appeaing a decision we made about a drug you have not yet received, you and your doctor or other prescriber wi need to decide if you need a fast appea. The requirements for getting a fast appea are the same as those for getting a fast coverage decision in Section 5.4 of this chapter. Step 2: We consider your appea and we give you our answer. When we are reviewing your appea, we take another carefu ook at a of the information about your coverage request. We check to see if we were foowing a the rues when we said no to your request. We may contact you or your doctor or other prescriber to get more information. Deadines for a fast appea If we are using the fast deadines, we must give you our answer within 72 hours after we receive your appea. We wi give you our answer sooner if your heath requires it. If we do not give you an answer within 72 hours, we are required to send your request on to Leve 2 of the appeas process, where it wi be reviewed by an Independent Review Organization. (Later in this section, we te about this review organization and expain what happens at Leve 2 of the appeas process.) If our answer is yes to part or a of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appea. If our answer is no to part or a of what you requested, we wi send you a written statement that expains why we said no and how to appea our decision. Deadines for a standard appea If we are using the standard deadines, we must give you our answer within 7 caendar days after we receive your appea. We wi give you our decision sooner if you have not received the drug yet and your heath condition

135 2015 Evidence of Coverage for WeCare Simpe (PDP) 130 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) requires us to do so. If you beieve your heath requires it, you shoud ask for fast appea. If we do not give you a decision within 7 caendar days, we are required to send your request on to Leve 2 of the appeas process, where it wi be reviewed by an Independent Review Organization. Later in this section, we te about this review organization and expain what happens at Leve 2 of the appeas process. If our answer is yes to part or a of what you requested If we approve a request for coverage, we must provide the coverage we have agreed to provide as quicky as your heath requires, but no ater than 7 caendar days after we receive your appea. If we approve a request to pay you back for a drug you aready bought, we are required to send payment to you within 30 caendar days after we receive your appea request. If our answer is no to part or a of what you requested, we wi send you a written statement that expains why we said no and how to appea our decision. Step 3: If we say no to your appea, you decide if you want to continue with the appeas process and make another appea. If we say no to your appea, you then choose whether to accept this decision or continue by making another appea. If you decide to make another appea, it means your appea is going on to Leve 2 of the appeas process (see beow). Section 5.6 Step-by-step: How to make a Leve 2 Appea If we say no to your appea, you then choose whether to accept this decision or continue by making another appea. If you decide to go on to a Leve 2 Appea, the Independent Review Organization reviews the decision our pan made when we said no to your first appea. This organization decides whether the decision we made shoud be changed.

136 2015 Evidence of Coverage for WeCare Simpe (PDP) 131 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Lega Terms The forma name for the Independent Review Organization is the Independent Review Entity. It is sometimes caed the IRE. Step 1: To make a Leve 2 Appea, 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 Leve 1 Appea, the written notice we send you wi incude instructions on how to make a Leve 2 Appea with the Independent Review Organization. These instructions wi te who can make this Leve 2 Appea, what deadines you must foow, and how to reach the review organization. When you make an appea to the Independent Review Organization, we wi send the information we have about your appea to this organization. This information is caed your case fie. You have the right to ask us for a copy of your case fie. You have a right to give the Independent Review Organization additiona information to support your appea. Step 2: The Independent Review Organization does a review of your appea and gives you an answer. The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us. Reviewers at the Independent Review Organization wi take a carefu ook at a of the information reated to your appea. The organization wi te you its decision in writing and expain the reasons for it. Deadines for fast appea at Leve 2 If your heath requires it, ask the Independent Review Organization for a fast appea. If the review organization agrees to give you a fast appea, the review organization must give you an answer to your Leve 2 Appea within 72 hours after it receives your appea request.

137 2015 Evidence of Coverage for WeCare Simpe (PDP) 132 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If the Independent Review Organization says yes to part or a 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. Deadines for standard appea at Leve 2 If you have a standard appea at Leve 2, the review organization must give you an answer to your Leve 2 Appea within 7 caendar days after it receives your appea. If the Independent Review Organization says yes to part or a of what you requested If the Independent Review Organization approves a 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 approves a request to pay you back for a drug you aready bought, we are required to send payment to you within 30 caendar days after we receive the decision from the review organization. What if the review organization says no to your appea? If this organization says no to your appea, it means the organization agrees with our decision not to approve your request. (This is caed uphoding the decision. It is aso caed turning down your appea. ) To continue and make another appea at Leve 3, the doar vaue of the drug coverage you are requesting must meet a minimum amount. If the doar vaue of the coverage you are requesting is too ow, you cannot make another appea and the decision at Leve 2 is fina. The notice you get from the Independent Review Organization wi te you the doar vaue that must be in dispute to continue with the appeas process. Step 3: If the doar vaue of the coverage you are requesting meets the requirement, you choose whether you want to take your appea further. There are three additiona eves in the appeas process after Leve 2 (for a tota of five eves of appea). If your Leve 2 Appea is turned down and you meet the requirements to continue with the appeas process, you must decide whether you want to go

138 2015 Evidence of Coverage for WeCare Simpe (PDP) 133 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) on to Leve 3 and make a third appea. If you decide to make a third appea, the detais on how to do this are in the written notice you got after your second appea. The Leve 3 Appea is handed by an administrative aw judge. Section 6 in this chapter tes more about Leves 3, 4, and 5 of the appeas process. SECTION 6 Section 6.1 Taking your appea to Leve 3 and beyond Leves of Appea 3, 4, and 5 for Part D Drug Appeas This section may be appropriate for you if you have made a Leve 1 Appea and a Leve 2 Appea, and both of your appeas have been turned down. If the vaue of the drug you have appeaed meets a certain doar amount, you may be abe to go on to additiona eves of appea. If the doar amount is ess, you cannot appea any further. The written response you receive to your Leve 2 Appea wi expain who to contact and what to do to ask for a Leve 3 Appea. For most situations that invove appeas, the ast three eves of appea work in much the same way. Here is who handes the review of your appea at each of these eves. Leve 3 Appea A judge who works for the Federa government wi review your appea and give you an answer. This judge is caed an Administrative Law Judge. If the answer is yes, the appeas process is over. What you asked for in the appea has been approved. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge within 72 hours (24 hours for expedited appeas) or make payment no ater than 30 caendar days after we receive the decision. If the Administrative Law Judge says no to your appea, the appeas process may or may not be over. If you decide to accept this decision that turns down your appea, the appeas process is over. If you do not want to accept the decision, you can continue to the next eve of the review process. If the administrative aw judge says no to your appea, the

139 2015 Evidence of Coverage for WeCare Simpe (PDP) 134 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) notice you get wi te you what to do next if you choose to continue with your appea. Leve 4 Appea The Appeas Counci wi review your appea and give you an answer. The Appeas Counci works for the Federa government. If the answer is yes, the appeas process is over. What you asked for in the appea has been approved. We must authorize or provide the drug coverage that was approved by the Appeas Counci within 72 hours (24 hours for expedited appeas) or make payment no ater than 30 caendar days after we receive the decision. If the answer is no, the appeas process may or may not be over. If you decide to accept this decision that turns down your appea, the appeas process is over. If you do not want to accept the decision, you might be abe to continue to the next eve of the review process. If the Appeas Counci says no to your appea or denies your request to review the appea, the notice you get wi te you whether the rues aow you to go on to a Leve 5 Appea. If the rues aow you to go on, the written notice wi aso te you who to contact and what to do next if you choose to continue with your appea. Leve 5 Appea A judge at the Federa District Court wi review your appea. This is the ast step of the appeas process. MAKING COMPLAINTS SECTION 7? How to make a compaint about quaity of care, waiting times, customer service, or other concerns If your probem is about decisions reated to benefits, coverage, or payment, then this section is not for you. Instead, you need to use the process for coverage decisions and appeas. Go to Section 4 of this chapter.

140 2015 Evidence of Coverage for WeCare Simpe (PDP) 135 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Section 7.1 What kinds of probems are handed by the compaint process? This section expains how to use the process for making compaints. The compaint process is used for certain types of probems ony. This incudes probems reated to quaity of care, waiting times, and the customer service you receive. Here are exampes of the kinds of probems handed by the compaint process. If you have any of these kinds of probems, you can make a compaint Compaint Quaity of your medica care Respecting your privacy Disrespect, poor customer service, or other negative behaviors Waiting times Ceaniness Information you get from us Exampe Are you unhappy with the quaity of the care you have received? Do you beieve that someone did not respect your right to privacy or shared information about you that you fee shoud be confidentia? Has someone been rude or disrespectfu to you? Are you unhappy with how our Customer Service has treated you? Do you fee you are being encouraged to eave the pan? Have you been kept waiting too ong by pharmacists? Or by our Customer Service or other staff at the pan? Exampes incude waiting too ong on the phone or when getting a prescription. Are you unhappy with the ceaniness or condition of a pharmacy? Do you beieve we have not given you a notice that we are required to give? Do you think written information we have given you is hard to understand?

141 2015 Evidence of Coverage for WeCare Simpe (PDP) 136 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Timeiness (These types of compaints are a reated to the timeiness of our actions reated to coverage decisions and appeas) The process of asking for a coverage decision and making appeas is expained in sections 4-6 of this chapter. If you are asking for a decision or making an appea, you use that process, not the compaint process. However, if you have aready asked us for a coverage decision or made an appea, and you think that we are not responding quicky enough, you can aso make a compaint about our sowness. Here are exampes: If you have asked us to give you a fast coverage decision or a fast appea, and we have said we wi not, you can make a compaint. If you beieve we are not meeting the deadines for giving you a coverage decision or an answer to an appea you have made, you can make a compaint. When a coverage decision we made is reviewed and we are tod that we must cover or reimburse you for certain drugs, there are deadines that appy. If you think we are not meeting these deadines, you can make a compaint. When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization. If we do not do that within the required deadine, you can make a compaint. Section 7.2 The forma name for making a compaint is fiing a grievance Lega Terms What this section cas a compaint is aso caed a grievance. Another term for making a compaint is fiing a grievance. Another way to say using the process for compaints is using the process for fiing a grievance.

142 2015 Evidence of Coverage for WeCare Simpe (PDP) 137 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Section 7.3 Step-by-step: Making a compaint Step 1: Contact us prompty - either by phone or in writing. Usuay, caing Customer Service is the first step. If there is anything ese you need to do, Customer Service wi et you know (TTY users shoud ca 711 ). 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. If you do not wish to ca (or you caed and were not satisfied), you can put your compaint in writing and send it to us. If you put your compaint in writing, we wi respond to your compaint in writing. A grievance (compaint) can be submitted in writing by mai, e-mai or fax. Send your request to: WeCare Attn: Grievance Department P.O. Box Tampa, FL Fax to: E-mai to: [email protected] A Standard grievance (compaint) is generay resoved within 30 days from the date we receive your request uness your heath or condition requires a quicker response. If additiona information is required or you ask for an extension, we may extend the timeframe by up to 14 days. A Grievance Coordinator wi contact you and/or your representative with the resoution. If we don t agree with your grievance in whoe or in part, our written decision wi expain why we don t agree with it, and wi te you about any dispute resoution options you may have. An Expedited grievance (fast compaint) is resoved within 24 hours. As a member of our Pan, you have the right to fie an Expedited Grievance in any of the foowing circumstances. If you disagree with our decision to process a request for an expedited coverage determination under the standard timeframe, rather than the expedited timeframe. If you disagree with our decision to extend a review of a coverage determination or appea timeframe.

143 2015 Evidence of Coverage for WeCare Simpe (PDP) 138 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) If you disagree with our decision to process your appea request under the standard timeframe, rather than the expedited timeframe. Whether you ca or write, you shoud contact Customer Service right away. The compaint must be made within 60 caendar days after you had the probem you want to compain about. If you are making a compaint because we denied your request for a fast coverage decision or a fast appea, we wi automaticay give you a fast compaint. If you have a fast compaint, it means we wi give you an answer within 24 hours. Lega Terms What this section cas a fast compaint is aso caed an expedited grievance. Step 2: We ook into your compaint and give you our answer. If possibe, we wi answer you right away. If you ca us with a compaint, we may be abe to give you an answer on the same phone ca. If your heath condition requires us to answer quicky, we wi do that. Most compaints are answered in 30 caendar days. If we need more information and the deay is in your best interest or if you ask for more time, we can take up to 14 more caendar days (44 caendar days tota) to answer your compaint. If we do not agree with some or a of your compaint or don t take responsibiity for the probem you are compaining about, we wi et you know. Our response wi incude our reasons for this answer. We must respond whether we agree with the compaint or not. Section 7.4 You can aso make compaints about quaity of care to the Quaity Improvement Organization You can make your compaint about the quaity of care you received to us by using the step-by-step process outined above. When your compaint is about quaity of care, you aso have two extra options: You can make your compaint to the Quaity Improvement Organization. If you prefer, you can make your compaint about the quaity of care you received directy to this organization (without making the compaint to us).

144 2015 Evidence of Coverage for WeCare Simpe (PDP) 139 Chapter 7: What to do if you have a probem or compaint (coverage decisions, appeas, compaints) The Quaity Improvement Organization is a group of practicing doctors and other heath care experts paid by the Federa government to check and improve the care given to Medicare patients. To find the name, address, and phone number of the Quaity Improvement Organization for your state, ook in the appendix at the back of this booket. If you make a compaint to this organization, we wi work with them to resove your compaint. Or you can make your compaint to both at the same time. If you wish, you can make your compaint about quaity of care to us and aso to the Quaity Improvement Organization. Section 7.5 You can aso te Medicare about your compaint You can 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 have any other feedback or concerns, or if you fee the pan is not addressing your issue, pease ca MEDICARE ( ). TTY users can ca

145 2015 Evidence of Coverage for WeCare Simpe (PDP) 140 Chapter 8: Ending your membership in the pan Chapter 8. Ending your membership in the pan SECTION 1 Introduction Section 1.1 This chapter focuses on ending your membership in our pan SECTION 2 When can you end your membership in our pan? Section 2.1 Usuay, you can end your membership during the Annua Enroment Period Section 2.2 In certain situations, you can end your membership during a Specia Enroment Period Section 2.3 Where can you get more information about when you can end your membership? SECTION 3 How do you end your membership in our pan? Section 3.1 Usuay, you end your membership by enroing in another pan SECTION 4 Unti your membership ends, you must keep getting your drugs through our pan Section 4.1 Unti your membership ends, you are sti a member of our pan SECTION 5 WeCare Simpe (PDP) must end your membership in the pan in certain situations Section 5.1 When must we end your membership in the pan? Section 5.2 We cannot ask you to eave our pan for any reason reated to your heath Section 5.3 You have the right to make a compaint if we end your membership in our pan

146 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 141 SECTION 1 Section 1.1 Introduction This chapter focuses on ending your membership in our pan Ending your membership in our pan may be vountary (your own choice) or invountary (not your own choice): You might eave our pan because you have decided that you want to eave. There are ony certain times during the year, or certain situations, when you may vountariy end your membership in the pan. Section 2 tes you when you can end your membership in the pan. The process for vountariy ending your membership varies depending on what type of new coverage you are choosing. Section 3 tes you how to end your membership in each situation. There are aso imited situations where you do not choose to eave, but we are required to end your membership. Section 5 tes you about situations when we must end your membership. If you are eaving our pan, you must continue to get your Part D prescription drugs through our pan unti your membership ends. SECTION 2 When can you end your membership in our pan? You may end your membership in our pan ony during certain times of the year, known as enroment periods. A members have the opportunity to eave the pan during the Annua Enroment Period. In certain situations, you may aso be eigibe to eave the pan at other times of the year. Section 2.1 Usuay, you can end your membership during the Annua Enroment Period You can end your membership during the Annua Enroment Period (aso known as the Annua Coordinated Eection Period ). This is the time when you shoud review your heath and drug coverage and make a decision about your coverage for the upcoming year. When is the Annua Enroment Period? This happens from October 15 to December 7. What type of pan can you switch to during the Annua Enroment Period? During this time, you can review your heath coverage and your prescription

147 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 142 drug coverage. You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new pan, you can choose any of the foowing types of pans: Another Medicare prescription drug pan. Origina Medicare without a separate Medicare prescription drug pan. u u If you receive "Extra Hep" from Medicare to pay for your prescription drugs: If you do not enro in a separate Medicare prescription drug pan, Medicare may enro you in a drug pan, uness you have opted out of automatic enroment. - or - A Medicare heath pan. A Medicare heath pan is a pan offered by a private company that contracts with Medicare to provide a of the Medicare Part A (Hospita) and Part B (Medica) benefits. Some Medicare heath pans aso incude Part D prescription drug coverage. If you enro in most Medicare heath pans, you wi be disenroed from our pan when your new pan s coverage begins. However, if you choose a Private Fee-for-Service pan without Part D drug coverage, a Medicare Medica Savings Account pan, or a Medicare Cost Pan, you can enro in that pan and keep our pan for your drug coverage. If you do not want to keep our pan, you can choose to enro in another Medicare prescription drug pan or drop Medicare prescription drug coverage. Note: If you disenro from Medicare prescription drug coverage and go without creditabe prescription drug coverage, you may need to pay a ate enroment penaty if you join a Medicare drug pan ater. ( Creditabe coverage means the coverage is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage.) See Chapter 4, Section 9 for more information about the ate enroment penaty. When wi your membership end? Your membership wi end when your new pan s coverage begins on January 1.

148 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 143 Section 2.2 In certain situations, you can end your membership during a Specia Enroment Period In certain situations, members of our pan may be eigibe to end their membership at other times of the year. This is known as a Specia Enroment Period. Who is eigibe for a Specia Enroment Period? If any of the foowing situations appy to you, you are eigibe to end your membership during a Specia Enroment Period. These are just exampes, for the fu ist you can contact the pan, ca Medicare, or visit the Medicare website ( If you have moved out of your pan s service area. If you have Medicaid. If you are eigibe for "Extra Hep" with paying for your Medicare prescriptions. If we vioate our contract with you. If you are getting care in an institution, such as a nursing home or ong-term care (LTC) hospita. PACE is not avaiabe in a states. If you woud ike to know if PACE is avaiabe in your state, pease contact Customer Service (phone numbers are printed on the back cover of this booket). When are Specia Enroment Periods? The enroment periods vary depending on your situation. What can you do? To find out if you are eigibe for a Specia Enroment Period, pease ca Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users ca If you are eigibe to end your membership because of a specia situation, you can choose to change both your Medicare heath coverage and prescription drug coverage. This means you can choose any of the foowing types of pans: Another Medicare prescription drug pan. Origina Medicare without a separate Medicare prescription drug pan. u If you receive "Extra Hep" from Medicare to pay for your prescription drugs: If you switch to Origina Medicare and do not enro

149 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 144 u in a separate Medicare prescription drug pan, Medicare may enro you in a drug pan, uness you have opted out of automatic enroment. - or - A Medicare heath pan. A Medicare heath pan is a pan offered by a private company that contracts with Medicare to provide a of the Medicare Part A (Hospita) and Part B (Medica) benefits. Some Medicare heath pans aso incude Part D prescription drug coverage. If you enro in most Medicare heath pans, you wi automaticay be disenroed from our pan when your new pan s coverage begins. However, if you choose a Private Fee-for-Service pan without Part D drug coverage, a Medicare Medica Savings Account pan, or a Medicare Cost Pan, you can enro in that pan and keep our pan for your drug coverage. If you do not want to keep our pan, you can choose to enro in another Medicare prescription drug pan or to drop Medicare prescription drug coverage. Note: If you disenro from Medicare prescription drug coverage and go without creditabe prescription drug coverage, you may need to pay a ate enroment penaty if you join a Medicare drug pan ater. ( Creditabe coverage means the coverage is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage.) See Chapter 4, Section 9 for more information about the ate enroment penaty. When wi your membership end? Your membership wi usuay end on the first day of the month after we receive your request to change your pan. Section 2.3 Where can you get more information about when you can end your membership? If you have any questions or woud ike more information on when you can end your membership: You can ca Customer Service (phone numbers are printed on the back cover of this booket). You can find the information in the Medicare & You 2015 Handbook. Everyone with Medicare receives a copy of Medicare & You each fa. Those new to Medicare receive it within a month after first signing up. You can aso downoad a copy from the Medicare website ( Or, you can order a printed copy by caing Medicare at the number beow.

150 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 145 You can contact Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca SECTION 3 Section 3.1 How do you end your membership in our pan? Usuay, you end your membership by enroing in another pan Usuay, to end your membership in our pan, you simpy enro in another Medicare pan during one of the enroment periods (see Section 2 in this chapter for information about the enroment periods). However, there are two situations in which you wi need to end your membership in a different way: If you want to switch from our pan to Origina Medicare without a Medicare prescription drug pan, you must ask to be disenroed from our pan. If you join a Private Fee-for-Service pan without prescription drug coverage, a Medicare Medica Savings Account Pan, or a Medicare Cost Pan, enroment in the new pan wi not end your membership in our pan. In this case, you can enro in that pan and keep our pan for your drug coverage. If you do not want to keep our pan, you can choose to enro in another Medicare prescription drug pan or ask to be disenroed from our pan. If you are in one of these two situations and want to eave our pan, there are two ways you can ask to be disenroed: You can make a request in writing to us. Contact Customer Service if you need more information on how to do this (phone numbers are printed on the back cover of this booket). --or--you can contact Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca Note: If you disenro from Medicare prescription drug coverage and go without creditabe prescription drug coverage, you may need to pay a ate enroment penaty if you join a Medicare drug pan ater. ( Creditabe coverage means the coverage is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage.) See Chapter 4, Section 9 for more information about the ate enroment penaty. The tabe beow expains how you shoud end your membership in our pan.

151 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 146 If you woud ike to switch from our pan to: This is what you shoud do: Another Medicare prescription drug pan. Enro in the new Medicare prescription drug pan. You wi automaticay be disenroed from our pan when your new pan s coverage begins. A Medicare heath pan. Enro in the Medicare heath pan. With most Medicare heath pans, you wi automaticay be disenroed from our pan when your new pan s coverage begins. However, if you choose a Private Fee-For-Service pan without Part D drug coverage, a Medicare Medica Savings Account pan, or a Medicare Cost Pan, you can enro in that new pan and keep our pan for your drug coverage. If you want to eave our pan, you must either enro in another Medicare prescription drug pan or ask to be disenroed. To ask to be disenroed, you must send us a written request (contact Customer Service (phone numbers are printed on the back cover of this booket) if you need more information on how to do this) or contact Medicare at MEDICARE ( ), 24 hours a day, 7 days a week (TTY users shoud ca ).

152 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 147 If you woud ike to switch from our pan to: This is what you shoud do: Origina Medicare without a separate Medicare prescription drug pan. Note: If you disenro from a Medicare prescription drug pan and go without creditabe prescription drug coverage, you may need to pay a ate enroment penaty if you join a Medicare drug pan ater. See Chapter 4, Section 9 for more information about the ate enroment penaty. Send us a written request to disenro. Contact Customer Service if you need more information on how to do this (phone numbers are printed on the back cover of this booket). You can aso contact Medicare at MEDICARE ( ), 24 hours a day, 7 days a week, and ask to be disenroed. TTY users shoud ca SECTION 4 Section 4.1 Unti your membership ends, you must keep getting your drugs through our pan Unti your membership ends, you are sti a member of our pan If you eave our pan, it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.) During this time, you must continue to get your prescription drugs through our pan. You shoud continue to use our network pharmacies to get your prescriptions fied unti your membership in our pan ends. Usuay, your prescription drugs are ony covered if they are fied at a network pharmacy incuding through our mai pharmacy services. SECTION 5 Section 5.1 WeCare Simpe (PDP) must end your membership in the pan in certain situations When must we end your membership in the pan?

153 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 148 Our pan must end your membership in the pan if any of the foowing happen: If you do not stay continuousy enroed in 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. If you move or take a ong trip, you need to ca Customer Service to find out if the pace you are moving or traveing to is in our pan s area. (Phone numbers for Customer Service are printed on the back cover of this booket.) If you become incarcerated (go to prison). If you ie about or withhod information about other insurance you have that provides prescription drug coverage. If you intentionay give us incorrect information when you are enroing in our pan and that information affects your eigibiity for our pan. (We cannot make you eave our pan for this reason uness we get permission from Medicare first.) If you continuousy behave in a way that is disruptive and makes it difficut for us to provide care for you and other members of our pan. (We cannot make you eave our pan for this reason uness we get permission from Medicare first.) If you et someone ese use your membership card to get prescription drugs. (We cannot make you eave our pan for this reason uness we get permission from Medicare first.) If we end your membership because of this reason, Medicare may have your case investigated by the Inspector Genera. If you do not pay the pan premiums for two (2) caendar months. We must notify you in writing that you have two (2) caendar months to pay the pan premium before we end your membership. If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare wi disenro you from our pan and you wi ose prescription drug coverage.

154 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 8: Ending your membership in the pan 149 Where can you get more information? If you have questions or woud ike more information on when we can end your membership: You can ca Customer Service for more information (phone numbers are printed on the back cover of this booket). Section 5.2 We cannot ask you to eave our pan for any reason reated to your heath WeCare Simpe (PDP) is not aowed to ask you to eave our pan for any reason reated to your heath. What shoud you do if this happens? If you fee that you are being asked to eave our pan because of a heath-reated reason, you shoud ca Medicare at MEDICARE ( ). TTY users shoud ca You may ca 24 hours a day, 7 days a week. Section 5.3 You have the right to make a compaint if we end your membership in our pan If we end your membership in our pan, we must te you our reasons in writing for ending your membership. We must aso expain how you can make a compaint about our decision to end your membership. You can aso ook in Chapter 7, Section 7 for information about how to make a compaint.

155 2015 Evidence of Coverage for WeCare Simpe (PDP) 150 Chapter 9: Lega notices Chapter 9. Lega notices SECTION 1 Notice about governing aw SECTION 2 Notice about nondiscrimination SECTION 3 Notice about Medicare Secondary Payer subrogation rights SECTION 4 Notice about third party iabiity and overpayments SECTION 5 Independent contractors...152

156 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 9: Lega notices 151 SECTION 1 Notice about governing aw Many aws appy to this Evidence of Coverage and some additiona provisions may appy because they are required by aw. This may affect your rights and responsibiities even if the aws are not incuded or expained in this document. The principa aw that appies to this document is Tite XVIII of the Socia Security Act and the reguations created under the Socia Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other Federa aws may appy and, under certain circumstances, the aws of the state you ive in. WeCare makes decisions on care based ony on appropriateness of care and service and existence of coverage. WeCare does not reward its associates or any practitioners, physicians or other individuas or entities performing Utiization Management (UM) activities for issuing denias of coverage, services or care. WeCare does not provide financia incentives to encourage or promote under-utiization. SECTION 2 Notice about nondiscrimination We don t discriminate based on a person s race, disabiity, reigion, sex, heath, ethnicity, creed, age, or nationa origin. A organizations that provide Medicare prescription drug pans, ike our pan, must obey federa aws against discrimination, incuding Tite VI of the Civi Rights Act of 1964, the Rehabiitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabiities Act, a other aws that appy to organizations that get Federa funding, and any other aws and rues that appy for any other reason. SECTION 3 Notice about Medicare Secondary Payer subrogation rights We have the right and responsibiity to coect for covered Medicare prescription drugs for which Medicare is not the primary payer. According to CMS reguations at 42 CFR sections and , WeCare Simpe (PDP), as a Medicare prescription drug pan sponsor, wi exercise the same rights of recovery that the Secretary exercises under CMS reguations in subparts B through D of part 411 of 42 CFR and the rues estabished in this section supersede any State aws. SECTION 4 Notice about third party iabiity and overpayments There may be instances when a third party or other insurance is responsibe for covering the cost of a member s heath care expenses. If our pan provides heath care benefits to a member for injuries or iness for which another party is responsibe,

157 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 9: Lega notices 152 then WeCare has the right to repayment of the fu cost of a benefits provided by us on behaf of the member. If the benefits paid by WeCare, pus the benefits paid by any third party, incuding other insurance pans, exceed the tota amount of expenses actuay incurred, then WeCare has the right to recover the amount of such excess payment. You are required to cooperate with us in pursuing such recoveries or over payments. SECTION 5 Independent contractors The reationship between WeCare and participating providers is an independent contractor reationship. Participating providers are not empoyees or agents of WeCare. In no case sha WeCare be iabe for the negigence, wrongfu acts or omissions of any participating providers.

158 2015 Evidence of Coverage for WeCare Simpe (PDP) 153 Chapter 10: Definitions of important words Chapter 10. Definitions of important words Appea An appea is something you do if you disagree with our decision to deny a request for coverage of prescription drugs or payment for drugs you aready received. For exampe, you may ask for an appea if we don t pay for a drug you think you shoud be abe to receive. Chapter 7 expains appeas, incuding the process invoved in making an appea. Annua Enroment Period A set time each fa when members can change their heath or drug pans or switch to Origina Medicare. The Annua Enroment Period is from October 15 unti December 7. Brand Name Drug A prescription drug that is manufactured and sod by the pharmaceutica company that originay researched and deveoped the drug. Brand-name drugs have the same active-ingredient formua as the generic version of the drug. However, generic drugs are manufactured and sod by other drug manufacturers and are generay not avaiabe unti after the patent on the brand-name drug has expired. Catastrophic Coverage Stage The stage in the Part D Drug Benefit where you pay a ow co-payment or coinsurance for your drugs after you or other quaified parties on your behaf have spent $4,700 in covered drugs during the covered year. Centers for Medicare & Medicaid Services (CMS) The Federa agency that administers Medicare. Chapter 2 expains how to contact CMS. Coinsurance An amount you may be required to pay as your share of the cost for prescription drugs after you pay any deductibes. Coinsurance is usuay a percentage (for exampe, 20%). Co-payment An amount you may be required to pay as your share of the cost for a prescription drug. A co-payment is usuay a set amount, rather than a percentage. For exampe, you might pay $10 or $20 for a prescription drug. Cost-Sharing Cost-sharing refers to amounts that a member has to pay when drugs are received. (This is in addition to the pan s monthy premium.) Cost-sharing incudes any combination of the foowing three types of payments: (1) any deductibe amount a pan may impose before drugs are covered; (2) any fixed co-payment amount that a pan requires when a specific drug is received; or (3) any coinsurance amount, a percentage of the tota amount paid for a drug, that a pan requires when a specific drug is received. A daiy cost-sharing rate may appy when your doctor prescribes ess than a fu month s suppy of certain drugs for you and you are required to pay a co-pay.

159 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 10: Definitions of important words 154 Cost-Sharing Tier Every drug on the ist of covered drugs is in one of five cost-sharing tiers. In genera, 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 pan and the amount, if any, you are required to pay for the prescription. In genera, if you bring your prescription to a pharmacy and the pharmacy tes you the prescription isn t covered under your pan, that isn t a coverage determination. You need to ca or write to your pan to ask for a forma decision about the coverage. Coverage determinations are caed coverage decisions in this booket. Chapter 7 expains how to ask us for a coverage decision. Covered Drugs The term we use to mean a of the prescription drugs covered by our pan. Creditabe Prescription Drug Coverage Prescription drug coverage (for exampe, from an empoyer or union) that is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. Peope who have this kind of coverage when they become eigibe for Medicare can generay keep that coverage without paying a penaty, if they decide to enro in Medicare prescription drug coverage ater. Customer Service A department within our pan responsibe for answering your questions about your membership, benefits, grievances, and appeas. See Chapter 2 for information about how to contact Customer Service. Daiy cost-sharing rate A daiy cost-sharing rate may appy when your doctor prescribes ess than a fu month s suppy of certain drugs for you and you are required to pay a co-pay. A daiy cost-sharing rate is the co-pay divided by the number of days in a month s suppy. Here is an exampe: If your co-pay for a one-month suppy of a drug is $30, and a one-month s suppy in your pan is 30 days, then your daiy cost-sharing rate is $1 per day. This means you pay $1 for each day s suppy when you fi your prescription. Deductibe The amount you must pay for prescriptions before our pan begins to pay. Disenro or Disenroment The process of ending your membership in our pan. Disenroment may be vountary (your own choice) or invountary (not your own choice). Dispensing Fee A fee charged each time a covered drug is dispensed to pay for the cost of fiing a prescription. The dispensing fee covers costs such as the pharmacist s time to prepare and package the prescription.

160 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 10: Definitions of important words 155 Emergency A medica emergency is when you, or any other prudent ayperson with an average knowedge of heath and medicine, beieve that you have medica symptoms that require immediate medica attention to prevent oss of ife, oss of a imb, or oss of function of a imb. The medica symptoms may be an iness, injury, severe pain, or a medica condition that is quicky getting worse. Evidence of Coverage (EOC) and Discosure Information This document, aong with your enroment form and any other attachments, riders, or other optiona coverage seected, which expains your coverage, what we must do, your rights, and what you have to do as a member of our pan. Exception A type of coverage determination that, if approved, aows you to get a drug that is not on your pan sponsor s formuary (a formuary exception), or get a non-preferred drug at the preferred cost-sharing eve (a tiering exception). You may aso request an exception if your pan sponsor requires you to try another drug before receiving the drug you are requesting, or the pan imits the quantity or dosage of the drug you are requesting (a formuary exception). Extra Hep A Medicare program to hep peope with imited income and resources pay Medicare prescription drug program costs, such as premiums, deductibes, 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. Generay, a "generic" drug works the same as a brand name drug and usuay costs ess. Grievance A type of compaint you make about us or one of our network pharmacies, incuding a compaint concerning the quaity of your care. This type of compaint does not invove coverage or payment disputes. Income Reated Monthy Adjustment Amount (IRMAA) If your income is above a certain imit, you wi pay an income-reated monthy adjustment amount in addition to your pan premium. For exampe, individuas with income greater than $85,000 and married coupes with income greater than $170,000 must pay a higher Medicare Part B (medica insurance) and Medicare prescription drug coverage premium amount. This additiona amount is caed the income-reated monthy adjustment amount. Less than 5% of peope with Medicare are affected, so most peope wi not pay a higher premium. Initia Coverage Limit The maximum imit of coverage under the Initia Coverage Stage.

161 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 10: Definitions of important words 156 Initia Coverage Stage This is the stage before your tota drug costs incuding amounts you ve paid and what our pan has paid on your behaf for the year have reached $2,960. Initia Enroment Period When you are first eigibe for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For exampe, if you re eigibe for Medicare when you turn 65, your Initia Enroment Period is the 7-month period that begins 3 months before the month you turn 65, incudes the month you turn 65, and ends 3 months after the month you turn 65. Late Enroment Penaty An amount added to your monthy premium for Medicare drug coverage if you go without creditabe coverage (coverage that is expected to pay, on average, at east as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as ong as you have a Medicare drug pan. There are some exceptions. For exampe, if you receive "Extra Hep" from Medicare to pay your prescription drug pan costs, the ate enroment penaty rues do not appy to you. If you receive "Extra Hep", you do not pay a ate enroment penaty. List of Covered Drugs (Formuary or Drug List ) A ist of prescription drugs covered by the pan. The drugs on this ist are seected by the pan with the hep of doctors and pharmacists. The ist incudes both brand name and generic drugs. Low Income Subsidy (LIS) See "Extra Hep" Medicaid (or Medica Assistance) A joint Federa and state program that heps with medica costs for some peope with ow incomes and imited resources. Medicaid programs vary from state to state, but most heath care costs are covered if you quaify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state. Medicay Accepted Indication A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 3, Section 3 for more information about a medicay accepted indication. Medicare The Federa heath insurance program for peope 65 years of age or oder, some peope under age 65 with certain disabiities, and peope with End-Stage Rena Disease (generay those with permanent kidney faiure who need diaysis or a kidney transpant). Peope with Medicare can get their Medicare heath coverage through Origina Medicare, a Medicare Cost Pan, a PACE pan, or a Medicare Advantage Pan. Medicare Advantage (MA) Pan Sometimes caed Medicare Part C. A pan offered by a private company that contracts with Medicare to provide you with a your Medicare Part A and Part B benefits. A Medicare Advantage Pan can be an HMO,

162 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 10: Definitions of important words 157 PPO, a Private Fee-for-Service (PFFS) pan, or a Medicare Medica Savings Account (MSA) pan. If you are enroed in a Medicare Advantage Pan, Medicare services are covered through the pan, and are not paid for under Origina Medicare. In most cases, Medicare Advantage Pans aso offer Medicare Part D (prescription drug coverage). These pans are caed Medicare Advantage Pans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eigibe to join any Medicare heath pan that is offered in their area, except peope with End-Stage Rena Disease (uness certain exceptions appy). Medicare Cost Pan A Medicare Cost Pan is a pan operated by a Heath Maintenance Organization (HMO) or Competitive Medica Pan (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 enroees who have reached the Coverage Gap Stage and who are not aready receiving Extra Hep. Discounts are based on agreements between the Federa government and certain drug manufacturers. For this reason, most, but not a, brand name drugs are discounted. Medicare-Covered Services Services covered by Medicare Part A and Part B. Medicare Heath Pan A Medicare heath pan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to peope with Medicare who enro in the pan. This term incudes a Medicare Advantage Pans, Medicare Cost Pans, Demonstration/Piot Programs, and Programs of A-incusive Care for the Edery (PACE). Medicare Prescription Drug Coverage (Medicare Part D) Insurance to hep pay for outpatient prescription drugs, vaccines, bioogicas, and some suppies not covered by Medicare Part A or Part B. Medigap (Medicare Suppement Insurance) Poicy Medicare suppement insurance sod by private insurance companies to fi gaps in Origina Medicare. Medigap poicies ony work with Origina Medicare. (A Medicare Advantage Pan is not a Medigap poicy.) Member (Member of our Pan, or Pan Member ) A person with Medicare who is eigibe to get covered services, who has enroed in our pan and whose enroment has been confirmed by the Centers for Medicare & Medicaid Services (CMS). Network Pharmacy A network pharmacy is a pharmacy where members of our pan can get their prescription drug benefits. We ca them network pharmacies because they contract with our pan. In most cases, your prescriptions are covered ony if they are fied at one of our network pharmacies.

163 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 10: Definitions of important words 158 Origina Medicare ( Traditiona Medicare or Fee-for-service Medicare) Origina Medicare is offered by the government, and not a private heath pan ike Medicare Advantage Pans and prescription drug pans. Under Origina Medicare, Medicare services are covered by paying doctors, hospitas, and other heath care providers payment amounts estabished by Congress. You can see any doctor, hospita, or other heath care provider that accepts Medicare. You must pay the deductibe. Medicare pays its share of the Medicare-approved amount, and you pay your share. Origina Medicare has two parts: Part A (Hospita Insurance) and Part B (Medica Insurance) and is avaiabe everywhere in the United States. Out-of-Network Pharmacy A pharmacy that doesn t have a contract with our pan to coordinate or provide covered drugs to members of our pan. As expained in this Evidence of Coverage, most drugs you get from out-of-network pharmacies are not covered by our pan uness certain conditions appy. 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 aso referred to as the member s out-of-pocket cost requirement. PACE pan A PACE (Program of A-Incusive Care for the Edery) pan combines medica, socia, and ong-term care (LTC) services for frai peope to hep peope stay independent and iving in their community (instead of moving to a nursing home) as ong as possibe, whie getting the high-quaity care they need. Peope enroed in PACE pans receive both their Medicare and Medicaid benefits through the pan. PACE is not avaiabe in a states. If you woud ike to know if PACE is avaiabe in your state, pease contact Customer Service (phone numbers are printed on the back cover of this booket). Part C See Medicare Advantage (MA) Pan. Part D The vountary Medicare Prescription Drug Benefit Program. (For ease of reference, we wi refer to the prescription drug benefit program as Part D.) Part D Drugs Drugs that can be covered under Part D. We may or may not offer a Part D drugs. (See your formuary for a specific ist of covered drugs.) Certain categories of drugs were specificay excuded by Congress from being covered as Part D drugs. Preferred cost-sharing Preferred cost-sharing means ower cost-sharing for certain covered Part D drugs at certain network pharmacies. Premium The periodic payment to Medicare, an insurance company, or a heath care pan for heath or prescription drug coverage. Prior Authorization Approva in advance to get certain drugs that may or may not be on our formuary. Some drugs are covered ony if your doctor or other network

164 2015 Evidence of Coverage for WeCare Simpe (PDP) Chapter 10: Definitions of important words 159 provider gets prior authorization from us. Covered drugs that need prior authorization are marked in the formuary. Quaity Improvement Organization (QIO) A group of practicing doctors and other heath care experts paid by the Federa government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state. Quantity Limits A management too that is designed to imit the use of seected drugs for quaity, safety, or utiization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. Service Area A geographic area where a prescription drug pan accepts members if it imits membership based on where peope ive. The pan may disenro you if you permanenty move out of the pan s service area. Specia Enroment Period A set time when members can change their heath or drug pans or return to Origina Medicare. Situations in which you may be eigibe for a Specia Enroment Period incude: if you move outside the service area, if you are getting Extra Hep with your prescription drug costs, if you move into a nursing home, or if we vioate our contract with you. Standard Cost-sharing Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a network pharmacy. Step Therapy A utiization too that requires you to first try another drug to treat your medica condition before we wi cover the drug your physician may have initiay prescribed. Suppementa Security Income (SSI) A monthy benefit paid by Socia Security to peope with imited income and resources who are disabed, bind, or age 65 and oder. SSI benefits are not the same as Socia Security benefits.

165 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 160 Appendix SECTION 1 Cost-Sharing Amount by State for WeCare Simpe (PDP) SECTION 2 List of State Heath Insurance Assistance Programs (SHIPs) SECTION 3 Quaity Improvement Organization (QIOs) SECTION 4 Medicaid State Agencies SECTION 5 State Pharmaceutica Assistance Programs (SPAPs) SECTION 6 AIDS Drug Assistance Programs (ADAP)

166 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 161 SECTION 1 Cost-Sharing Amount by State for WeCare Simpe (PDP) Standard retai and maiservice costsharing (in-network) Preferred retai costsharing (in-network) 30-day suppy Tier 1 Preferred Generic Drugs 31-day suppy Preferred maiservice costsharing Out-of Network costsharing Long-Term Care (LTC) costsharing Standard retai and mai-service cost-sharing (in-network) 90-day suppy Preferred retai cost-sharing (in-network) Preferred maiservice costsharing State Pan AL S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 AR S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 ID S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 LA S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 MO S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 MS S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 OK S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 OR S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 SC S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 TN S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 TX S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 UT S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 VA S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 WA S $9.00 $0.00 $0.00 $9.00 $9.00 $27.00 $0.00 $0.00 Note: You may aso be responsibe for paying the difference between the out-of-network pharmacy charge and the in-network charge pus your co-payment or coinsurance for your prescription.

167 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 162 SECTION 1 Cost-Sharing Amount by State for WeCare Simpe (PDP) Standard retai and maiservice costsharing (in-network) Preferred retai costsharing (in-network) 30-day suppy Tier 2 Non-Preferred Generic Drugs 31-day suppy Preferred maiservice costsharing Out-of Network costsharing Long-Term Care (LTC) costsharing Standard retai and mai-service cost-sharing (in-network) 90-day suppy Preferred retai cost-sharing (in-network) Preferred maiservice costsharing State Pan AL S $29.00 $2.00 $2.00 $29.00 $29.00 $87.00 $6.00 $5.00 AR S $25.00 $2.00 $2.00 $25.00 $25.00 $75.00 $6.00 $5.00 ID S $25.00 $2.00 $2.00 $25.00 $25.00 $75.00 $6.00 $5.00 LA S $29.00 $4.00 $4.00 $29.00 $29.00 $87.00 $12.00 $10.00 MO S $29.00 $5.00 $5.00 $29.00 $29.00 $87.00 $15.00 $12.50 MS S $29.00 $3.00 $3.00 $29.00 $29.00 $87.00 $9.00 $7.50 OK S $29.00 $6.00 $6.00 $29.00 $29.00 $87.00 $18.00 $15.00 OR S $25.00 $2.00 $2.00 $25.00 $25.00 $75.00 $6.00 $5.00 SC S $29.00 $5.00 $5.00 $29.00 $29.00 $87.00 $15.00 $12.50 TN S $29.00 $2.00 $2.00 $29.00 $29.00 $87.00 $6.00 $5.00 TX S $29.00 $6.00 $6.00 $29.00 $29.00 $87.00 $18.00 $15.00 UT S $25.00 $2.00 $2.00 $25.00 $25.00 $75.00 $6.00 $5.00 VA S $29.00 $2.00 $2.00 $29.00 $29.00 $87.00 $6.00 $5.00 WA S $25.00 $2.00 $2.00 $25.00 $25.00 $75.00 $6.00 $5.00 Note: You may aso be responsibe for paying the difference between the out-of-network pharmacy charge and the in-network charge pus your co-payment or coinsurance for your prescription.

168 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 163 SECTION 1 Cost-Sharing Amount by State for WeCare Simpe (PDP) Standard retai and maiservice costsharing (in-network) Preferred retai costsharing (in-network) 30-day suppy Tier 3 Preferred Brand Drugs 31-day suppy Preferred maiservice costsharing Out-of Network costsharing Long-Term Care (LTC) costsharing Standard retai and mai-service cost-sharing (in-network) 90-day suppy Preferred retai cost-sharing (in-network) Preferred maiservice costsharing State Pan AL S $45.00 $37.00 $37.00 $45.00 $45.00 $ $ $92.50 AR S $45.00 $35.00 $35.00 $45.00 $45.00 $ $ $87.50 ID S $45.00 $35.00 $35.00 $45.00 $45.00 $ $ $87.50 LA S $45.00 $37.00 $37.00 $45.00 $45.00 $ $ $92.50 MO S $45.00 $40.00 $40.00 $45.00 $45.00 $ $ $ MS S $45.00 $37.00 $37.00 $45.00 $45.00 $ $ $92.50 OK S $45.00 $36.00 $36.00 $45.00 $45.00 $ $ $90.00 OR S $45.00 $35.00 $35.00 $45.00 $45.00 $ $ $87.50 SC S $45.00 $38.00 $38.00 $45.00 $45.00 $ $ $95.00 TN S $45.00 $37.00 $37.00 $45.00 $45.00 $ $ $92.50 TX S $45.00 $39.00 $39.00 $45.00 $45.00 $ $ $97.50 UT S $45.00 $35.00 $35.00 $45.00 $45.00 $ $ $87.50 VA S $45.00 $40.00 $40.00 $45.00 $45.00 $ $ $ WA S $45.00 $35.00 $35.00 $45.00 $45.00 $ $ $87.50 Note: You may aso be responsibe for paying the difference between the out-of-network pharmacy charge and the in-network charge pus your co-payment or coinsurance for your prescription.

169 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 164 SECTION 1 Cost-Sharing Amount by State for WeCare Simpe (PDP) Standard retai and maiservice costsharing (in-network) Preferred retai costsharing (in-network) 30-day suppy Tier 4 Non-Preferred Brand Drugs 31-day suppy Preferred maiservice costsharing Out-of Network costsharing Long-Term Care (LTC) costsharing Standard retai and mai-service cost-sharing (in-network) 90-day suppy Preferred retai cost-sharing (in-network) Preferred maiservice costsharing State Pan AL S $95.00 $87.00 $87.00 $95.00 $95.00 $ $ $ AR S $95.00 $84.00 $84.00 $95.00 $95.00 $ $ $ ID S $95.00 $94.00 $94.00 $95.00 $95.00 $ $ $ LA S $95.00 $88.00 $88.00 $95.00 $95.00 $ $ $ MO S $95.00 $88.00 $88.00 $95.00 $95.00 $ $ $ MS S $95.00 $88.00 $88.00 $95.00 $95.00 $ $ $ OK S $95.00 $86.00 $86.00 $95.00 $95.00 $ $ $ OR S $95.00 $87.00 $87.00 $95.00 $95.00 $ $ $ SC S $95.00 $87.00 $87.00 $95.00 $95.00 $ $ $ TN S $95.00 $87.00 $87.00 $95.00 $95.00 $ $ $ TX S $95.00 $89.00 $89.00 $95.00 $95.00 $ $ $ UT S $95.00 $94.00 $94.00 $95.00 $95.00 $ $ $ VA S $95.00 $88.00 $88.00 $95.00 $95.00 $ $ $ WA S $95.00 $87.00 $87.00 $95.00 $95.00 $ $ $ Note: You may aso be responsibe for paying the difference between the out-of-network pharmacy charge and the in-network charge pus your co-payment or coinsurance for your prescription.

170 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 165 SECTION 1 Cost-Sharing Amount by State for WeCare Simpe (PDP) Standard retai and mai-service cost-sharing (in-network) Preferred retai cost-sharing (in-network) Tier 5 Speciaty Tier Drugs 30-day suppy Preferred mai-service cost-sharing 31-day suppy Long-Term Care (LTC) cost-sharing Out-of-Network State Pan cost-sharing AL S % 25% 25% 25% 25% AR S % 25% 25% 25% 25% ID S % 25% 25% 25% 25% LA S % 25% 25% 25% 25% MO S % 25% 25% 25% 25% MS S % 25% 25% 25% 25% OK S % 25% 25% 25% 25% OR S % 25% 25% 25% 25% SC S % 25% 25% 25% 25% TN S % 25% 25% 25% 25% TX S % 25% 25% 25% 25% UT S % 25% 25% 25% 25% VA S % 25% 25% 25% 25% WA S % 25% 25% 25% 25% Note: You may aso be responsibe for paying the difference between the out-of-network pharmacy charge and the in-network charge pus your co-payment or coinsurance for your prescription.

171 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 166 SECTION 2 List of State Heath Insurance Assistance Programs (SHIPs) State SHIP Agency Address City, State, Zip Phone Number/TTY Web Address Aabama State Heath Insurance Montgomery, AL Assistance Program TTY: 711 Arkansas Idaho Louisiana Mississippi Senior Heath Insurance Information Program Senior Heath Insurance Benefits Advisors (SHIBA) Senior Heath Insurance Information Program State Heath Insurance Assistance Program 770 Washington Avenue, RSA Paza, Suite W Third Street Litte Rock, AR West State Street, P.O. Box P.O. Box Missouri CLAIM 200 North Keene Street, Suite 101 Okahoma Oregon Okahoma Senior Heath Insurance Counseing Program Senior Heath Insurance Benefits Assistance (SHIBA) TTY: 711 Boise, ID TTY: 711 Baton Rouge, LA TTY: N State Street Jackson, MS TTY: Corporate Paza, 3625 NW 56th Street, Suite Winter ST NE, RM 330 Coumbia, MO TTY: 711 Okahoma City, OK TTY: 711 Saem, OR TTY: geine.gov/heathcare arkansas.gov/shiip.ht m gov e.ms.us/aas_ship aim.org k.gov v

172 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 167 State SHIP Agency Address City, State, Zip Phone Number/TTY Web Address South Caroina Insurance Counseing Assistance and Referras for Eders (I-CARE) Tennessee Texas Utah Virginia Washington State Heath Insurance Assistance Program Heath Information Counseing and Advocacy Program (HICAP) Heath Insurance Information Program (HIIP) Virginia Insurance Counseing and Assistance Program (VICAP) Statewide Heath Insurance Benefits Advisors (SHIBA) 1301 Gervais Street., Suite Deaderick Street, 8th Foor 701 West 51st Street, MC: W N 1950 W Sat Lake City, UT Forest Avenue, Suite Capita Bvd Tumwater, WA Coumbia, SC TTY: 711 Nashvie, TN TTY: 711 Austin, TX TTY: TTY: 711 Richmond, VA TTY: TTY: ges/externa.aspx?htt ps://scaccess.commu nityos.org/ /comaging/ship.htm ov/consumer/hicap/hi caphme.htm ah.gov/hiip_contact_i st.htm a.gov wa.gov/about-oic/wh at-we-do/advocate-fo r-consumers/shiba/

173 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 168 SECTION 3 Quaity Improvement Organization (QIOs) Area/States QIO Agency Address City, State, Zip Phone Number/TTY Web Address Area 1: Connecticut Maine Massachusetts New Hampshire New Jersey New York Pennsyvania Rhode Isand Vermont Area 2: Deaware District Of Coumbia Forida Georgia Maryand North Caroina South Caroina Virginia West Virginia Livanta KEPRO BFCC-QIO Program 9090 Junction Drive, Suite W. Kennedy Bvd., Suite 900 Annapois Junction, MD Tampa, FL Phone Number: TTY: Fax: Appeas: A other reviews: Phone Number: TTY: 711 Fax: com

174 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 169 Area/States QIO Agency Address City, State, Zip Phone Number/TTY Web Address Area 3: Aabama Arkansas Coorado Kentucky Louisiana Mississippi Montana New Mexico North Dakota Okahoma South Dakota Tennessee Texas Utah Wyoming KEPRO 5700 Lombardo Center Dr., Suite 100 Seven His, OH Phone Number: TTY: 711 Fax:

175 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 170 Area/States QIO Agency Address City, State, Zip Phone Number/TTY Web Address Area 4: Iinois Indiana Iowa Kansas Michigan Minnesota Missouri Nebraska Ohio Area 5: Aaska Arizona Caifornia Hawaii Idaho Nevada Oregon Washington KEPRO Livanta 5201 W. Kennedy Bvd., Suite 900 BFCC-QIO Program 9090 Junction Drive, Suite 10 Tampa, FL Annapois Junction, MD Phone Number: TTY: 711 Fax: Phone Number: TTY: Fax: Appeas: A other reviews: com

176 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 171 SECTION 4 Medicaid State Agencies State Medicaid Agency Address City, State, Zip Phone Number/TTY Web Address Aabama Aabama Medicaid Agency 501 Dexter Avenue Montgomery, AL TTY: aabama.gov/ Arkansas Idaho Louisiana Mississippi Missouri Okahoma Arkansas Department of Human Services Idaho Department of Heath and Wefare Department of Heath & Hospitas Mississippi Division of Medicaid Missouri Department of Socia Services, MO HeathNet Division Okahoma Department of Human Services, SoonerCare Donaghey Paza, P. O. Box 1437 PO Box Litte Rock, AR Boise, ID N. 4th Street Baton Rouge, LA Siers Buiding, 550 High Street, Suite Howerton Court, P.O. Box 6500 Jackson, MS Jefferson City, MO N. Lincon Bvd Okahoma City, OK TTY: TTY: TTY: TTY: TTY: TTY: arkansas.gov/pages/ defaut.aspx wefare.idaho.gov/me dica/medicaid/tabid/1 23/Defaut.aspx na.gov/index.cfm/sub home/1/n/10 ms.gov/ v/mhd/index.htm programsandservices /heath/med/

177 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 172 State Medicaid Agency Address City, State, Zip Phone Number/TTY Web Address Oregon Oregon Heath Pan (OHP), Div. of Medica Assistance Programs (DMAP) South Caroina South Caroina Department of Heath and Human Services 500 Summer Street NE Saem, OR TTY: 711 P.O. Box 8206 Coumbia, SC TTY: Tennessee TennCare 310 Great Circe Rd Nashvie, TN TTY: 711 Texas Utah Virginia Washington Texas Heath and Human Services Commission Utah Department of Human Services Department of Medica Assistance Services (DMAS) Washington State Department of Socia and Heath Services Brown-Heaty Buiding, 4900 N. Lamar Bvd Austin, TX North 1950 West Sat Lake City, UT TTY: TTY: East Broad Street Richmond, VA TTY: P.O. Box Oympia, WA TTY: v/oha/heathpan/ind ex.shtm v/index.asp ncare/index.htm v/index.htm irginia.gov/defaut.as px ov/

178 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 173 SECTION 5 State Pharmaceutica Assistance Programs (SPAPs) State SPAP Agency Address City, State, Zip Phone Number/TTY Web Address Idaho Idaho HIV State Prescription Assistance Program (IDAGAP) P.O. Box Boise, ID TTY: e.idaho.gov/heath/f amiypanningstdhi V/HIVCareandTreatm ent/tabid/391/defaut. aspx Missouri Missouri Rx Pan (MoRx) P.O. Box 6500 Jefferson City, MO Texas Texas Virginia Washington Texas Kidney Heath Care Program (KHC) Texas HIV Medication Program (THMP) Virginia Department of Heath, State Pharmaceutica Assistance Program (SPAP) Washington Prescription Drug Program (WPDP) Department of State Heath Services, MC 1938, P.O. Box ATTN: MSJA, MC 1873, P.O. Box P.O. Box 5930 P.O. Box Austin, TX Austin, TX Midothian, VA Seatte, WA TTY: TTY: TTY: TTY: TTY: gov/ faut.shtm va.us/epidemioogy/ DiseasePrevention/s pap.htm

179 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 174 SECTION 6 AIDS Drug Assistance Programs (ADAP) State ADAP Agency Address City, State, Zip Phone Number/TTY Web Address Aabama Aabama Department of Pubic Heath, AIDS Drug Assistance Program, HIV/AIDS Division 201 Monroe Street, Suite 1400 Montgomery, AL TTY: aids/defaut.asp?id= 1001 Arkansas Idaho Louisiana Mississippi Arkansas HIV/STD/Hepatitis C, ADAP Division Idaho Department of Heath and Wefare Louisiana Heath Access Program (LAHAP) Mississippi AIDS Drug Assistance Program 4815 W. Markham Street 450 W. State Street, 4th Foor, P.O. Box Poydras Street, Suite E. Woodrow Wison Avenue, Post Office Box 1700 Litte Rock, AR Boise, ID New Oreans, LA Jackson, MS TTY: TTY: TTY: TTY: kansas.gov/programs Services/infectiousDi sease/hivstdhepatitis C/Pages/ADAP.aspx wefare.idaho.gov/he ath/famiypanning, STDHIV/HIVCareand Treatment/tabid/391/ Defaut.aspx munity/defaut.htm sdhsite/_static/14,13 047,150.htm

180 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 175 State ADAP Agency Address City, State, Zip Phone Number/TTY Web Address Missouri Okahoma Oregon Missouri AIDS Drug Assistance Program Okahoma AIDS Drug Assistance Program Oregon CAREAssist Program South Caroina South Caroina AIDS Drug Assistance Program Tennessee Texas Tennessee HIV Drug Assistance Program (HDAP) Texas HIV/STD Medication Program (THMP) 930 Widwood Drive Jefferson City, MO NE 10th Street, Room 614 P.O. Box Okahoma City, OK Portand, OR TTY: TTY: TTY: Bu Street Coumbia, SC TTY: James Robertson Parkway Nashvie, TN TTY: W. 49th Street Austin, TX TTY: ving/heathcondiseas es/communicabe/hiv aids/ ath/disease,_preven tion,_preparedness/ HIV_STD_Service/ v/oha/pharmacy/care assist/pages/index.a spx v/heath/diseasesan dconditions/infectiou sdiseases/hivandst Ds/AIDSDrugAssista ncepan/ s/std/ryanwhite.sht m faut.shtm

181 2015 Evidence of Coverage for WeCare Simpe (PDP) Appendix 176 State ADAP Agency Address City, State, Zip Phone Number/TTY Web Address Utah Virginia Washington Utah AIDS Drug Assistance Program Virginia Department of Heath (VDH) AIDS Drug Assistance Program Washington State's AIDS Drug Assistance Program 288 North 1460 West, PO Box Governor Street, James Madison Buiding 1610 NE 150th Street, MS: K17-9 Sat Lake City, UT TTY: 711 Richmond, VA TTY: 711 Shoreine, WA TTY: epi/diseases/hivaids/i ndex.htm va.us/epidemioogy/di seaseprevention/pro grams/adap/ v/youandyourfamiy/ InessandDisease/HI VAIDS/HIVCareCien tservices/adapande IP.aspx

182

183 Method WeCare Simpe (PDP) Customer Service Contact Information CALL TTY 711 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. 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 The State Heath Insurance Assistance Program is a state program that gets money from the Federa government to give free oca heath insurance counseing to peope with Medicare. You can find the name, phone number and address of the SHIP for your state in the appendix at the back of this booket.