Medi-Pak Advantage MA-PD Option 1 (PFFS) is a Medicare Advantage organization with a Medicare contract.

Transcription

1 January 1 December 31, 2011 Evidence f Cverage: Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) This bklet gives yu the details abut yur Medicare health and prescriptin drug cverage frm January 1 December 31, It explains hw t get the health care and prescriptin drugs yu need. This is an imprtant legal dcument. Please keep it in a safe place. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Member Services: Fr help r infrmatin, please call Member Services r g t ur plan website at r call , Mnday Friday, 8 am t 8 pm. (Calls t these numbers are free.) TTY users call: This plan is ffered by Arkansas Blue Crss and Blue Shield, referred thrughut the Evidence f Cverage as we, us, r ur. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is referred t as plan r ur plan. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is a Medicare Advantage rganizatin with a Medicare cntract. This infrmatin is available in a different frmat, including audi CD. Please call Member Services at the number listed abve if yu need plan infrmatin in anther frmat r language. Benefits, frmulary, pharmacy netwrk, premium and/r cpayments/c-insurance may change n January 1, H4213_REV1_EOC_MAPD1_A2 File & Use 09/21/2010

2 Table f Cntents Table f Cntents This list f chapters and page numbers is just yur starting pint. Fr mre help in finding infrmatin yu need, g t the first page f a chapter. Yu will find a detailed list f tpics at the beginning f each chapter. Chapter 1. Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 1 Tells what it means t be in a Medicare health plan and hw t use this bklet. Tells abut materials we will send yu, yur plan premium, yur plan membership card, and keeping yur membership recrd up t date. Chapter 2. Imprtant phne numbers and resurces 10 Tells yu hw t get in tuch with ur plan (Medi-Pak Advantage MA-PD Optin 1 (PFFS)) and with ther rganizatins including Medicare, the State Health Insurance Assistance Prgram, the Quality Imprvement Organizatin, Scial Security, Medicaid (the state health insurance prgram fr peple with lw incmes), prgrams that help peple pay fr their prescriptin drugs, and the Railrad Retirement Bard. Chapter 3. Using the plan s cverage fr yur medical services 21 Explains imprtant things yu need t knw abut getting yur medical care as a member f ur plan. Tpics include using the prviders in the plan s netwrk and hw t get care when yu have an emergency. Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 29 Gives the details abut which types f medical care are cvered and nt cvered fr yu as a member f ur plan. Tells hw much yu will pay as yur share f the cst fr yur cvered medical care. Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 48 Explains rules yu need t fllw when yu get yur Part D drugs. Tells hw t use the plan s List f Cvered Drugs (Frmulary) t find ut which drugs are cvered. Tells which kinds f drugs are nt cvered. Explains several kinds f restrictins that apply t yur cverage fr certain drugs. Explains where t get yur prescriptins filled. Tells abut the plan s prgrams fr drug safety and managing medicatins.

3 Table f Cntents Chapter 6. What yu pay fr yur Part D prescriptin drugs 64 Tells abut the fur stages f drug cverage (Deductible Stage, Initial Cverage Stage, Cverage Gap Stage, Catastrphic Cverage Stage) and hw these stages affect what yu pay fr yur drugs. Explains the 4 cst-sharing tiers fr yur Part D drugs and tells what yu must pay fr (cpayments r cinsurance) as yur share f the cst fr a drug in each cst-sharing tier. Tells abut the late enrllment penalty. Chapter 7. Asking the plan t pay its share f a bill yu have received fr cvered services r drugs 78 Tells when and hw t send a bill t us when yu want t ask us t pay yu back fr ur share f the cst fr yur cvered services. Chapter 8. Yur rights and respnsibilities 84 Explains the rights and respnsibilities yu have as a member f ur plan. Tells what yu can d if yu think yur rights are nt being respected. Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 92 Tells yu step-by-step what t d if yu are having prblems r cncerns as a member f ur plan. Explains hw t ask fr cverage decisins and make appeals if yu are having truble getting the medical care r prescriptin drugs yu think are cvered by ur plan. This includes asking us t make exceptins t the rules r extra restrictins n yur cverage fr prescriptin drugs, and asking us t keep cvering hspital care and certain types f medical services if yu think yur cverage is ending t sn. Explains hw t make cmplaints abut quality f care, waiting times, custmer service, and ther cncerns. Chapter 10. Ending yur membership in the plan 137 Tells when and hw yu can end yur membership in the plan. Explains situatins in which ur plan is required t end yur membership. Chapter 11. Legal ntices 144 Includes ntices abut gverning law and abut nndiscriminatin. Chapter 12. Definitins f imprtant wrds 146 Explains key terms used in this bklet.

4 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 1 Chapter 1. Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) SECTION 1 Intrductin 2 Sectin 1.1 What is the Evidence f Cverage bklet abut? 2 Sectin 1.2 What des this Chapter tell yu? 2 Sectin 1.3 What if yu are new t Medi-Pak Advantage MA-PD Optin 1 (PFFS)? 2 Sectin 1.4 Legal infrmatin abut the Evidence f Cverage 2 SECTION 2 What makes yu eligible t be a plan member? 3 Sectin 2.1 Yur eligibility requirements 3 Sectin 2.2 What are Medicare Part A and Medicare Part B? 3 Sectin 2.3 Here is the plan service area fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) 3 SECTION 3 What ther materials will yu get frm us? 4 Sectin 3.1 Yur plan membership card Use it t get all cvered care and drugs 4 Sectin 3.2 The Prvider Directry: yur guide t all prviders in the plan s netwrk 4 Sectin 3.3 The Pharmacy Directry: yur guide t pharmacies in ur netwrk 5 Sectin 3.4 The plan s List f Cvered Drugs (Frmulary) 5 Sectin 3.5 Reprts with a summary f payments made fr yur prescriptin drugs 6 SECTION 4 Yur mnthly premium fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) 6 Sectin 4.1 Hw much is yur plan premium? 6 Sectin 4.2 There are several ways yu can pay yur plan premium 7 Sectin 4.3 Can we change yur mnthly plan premium during the year? 8 SECTION 5 Please keep yur plan membership recrd up t date 9 Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu 9

5 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 2 SECTION 1 Intrductin Sectin 1.1 What is the Evidence f Cverage bklet abut? This Evidence f Cverage bklet tells yu hw t get yur Medicare medical care and prescriptin drugs thrugh ur plan, a Medicare Advantage Plan. This bklet explains yur rights and respnsibilities, what is cvered, and what yu pay as a member f the plan. Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care and yur prescriptin drug cverage thrugh ur plan, Medi-Pak Advantage MA-PD Optin 1 (PFFS). There are different types f Medicare Advantage Plans. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is a Medicare Advantage Plan PFFS plan (PFFS stands fr Private Fee-fr-Service). This plan is ffered by Arkansas Blue Crss and Blue Shield, referred thrughut the Evidence f Cverage as we, us, r ur. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is referred t as plan r ur plan. The wrd cverage and cvered services refers t the medical care and services and the prescriptin drugs available t yu as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS). Sectin 1.2 What des this Chapter tell yu? Lk thrugh Chapter 1 f this Evidence f Cverage t learn: What makes yu eligible t be a plan member? What is yur plans service area? What materials will yu get frm us? What is yur plan premium and hw can yu pay it? Hw d yu keep the infrmatin in yur membership recrd up t date? Sectin 1.3 What if yu are new t Medi-Pak Advantage MA-PD Optin 1 (PFFS)? If yu are a new member, then it s imprtant fr yu t learn hw the plan perates what the rules are and what services are available t yu. We encurage yu t set aside sme time t lk thrugh this Evidence f Cverage bklet. If yu are cnfused r cncerned r just have a questin, please cntact ur plan s Member Services (cntact infrmatin is n the cver f this bklet). Sectin 1.4 Legal infrmatin abut the Evidence f Cverage It s part f ur cntract with yu This Evidence f Cverage is part f ur cntract with yu abut hw Medi-Pak Advantage MA-PD Optin 1 (PFFS) cvers yur care. Other parts f this cntract include yur enrllment frm, the List f Cvered Drugs (Frmulary), and any ntices yu receive frm us abut changes t yur cverage r cnditins that affect yur cverage. These ntices are smetimes called riders r amendments.

6 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 3 The cntract is in effect fr mnths in which yu are enrlled in Medi-Pak Advantage MA-PD Optin 1 (PFFS) between January 1, 2011 t December 31, Medicare must apprve ur plan each year Medicare (the Centers fr Medicare & Medicaid Services) must apprve Medi-Pak Advantage MA-PD Optin 1 (PFFS) each year. Yu can cntinue t get Medicare cverage as a member f ur plan nly as lng as we chse t cntinue t ffer the plan fr the year in questin and the Centers fr Medicare & Medicaid Services renews its apprval f the plan. SECTION 2 What makes yu eligible t be a plan member? Sectin 2.1 Yur eligibility requirements Yu are eligible fr membership in ur plan as lng as: Yu live in ur gegraphic service area (sectin 2.3 belw describes ur service area) -- and -- yu are entitled t Medicare Part A -- and -- yu are enrlled in Medicare Part B. -- and -- yu d nt have End Stage Renal Disease (ESRD), with limited exceptins, such as if yu develp ESRD when yu are already a member f a plan that we ffer, r yu were a member f a different plan that was terminated. Sectin 2.2 What are Medicare Part A and Medicare Part B? When yu riginally signed up fr Medicare, yu received infrmatin abut hw t get Medicare Part A and Medicare Part B. Remember: Medicare Part A generally cvers services furnished by institutinal prviders such as hspitals, skilled nursing facilities r hme health agencies. Medicare Part B is fr mst ther medical services, such as physician s services and ther utpatient services. Sectin 2.3 Here is the plan service area fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) Althugh Medicare is a Federal prgram, Medi-Pak Advantage MA-PD Optin 1 (PFFS) is available nly t individuals wh live in ur plan service area. T stay a member f ur plan, yu must keep living in this service area. The service area is described belw. Our service area includes these cunties in Arkansas: Ashley, Bradley, Cleveland, Craighead, Crittenden, Dallas, Faulkner, Grant, Hward, Izard, Jeffersn, Lnke, Miller, Mnre, Mntgmery, Nevada, Pike, Pinsett, Plk, Pulaski, Sevier, Sharp, Unin, Wdruff, Yell Our service area includes these parts f cunties in Arkansas: Sme Central, Suthern and Eastern AR cunties. If yu plan t mve ut f the service area, please cntact Member Services.

7 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 4 SECTION 3 What ther materials will yu get frm us? Sectin 3.1 Yur plan membership card Use it t get all cvered care and drugs While yu are a member f ur plan, yu must use yur membership card fr ur plan whenever yu get any services cvered by this plan and fr prescriptin drugs yu get at netwrk pharmacies. Here s a sample membership card t shw yu what yurs will lk like: As lng as yu are a member f ur plan yu must nt use yur red, white, and blue Medicare card t get cvered medical services (with the exceptin f rutine clinical research and hspice services). Keep yur red, white, and blue Medicare card in a safe place in case yu need it later. Here s why this is s imprtant: If yu get cvered services using yur red, white, and blue Medicare card instead f using yur Medi-Pak Advantage MA-PD Optin 1 (PFFS) membership card while yu are a plan member, yu may have t pay the full cst yurself. If yur plan membership card is damaged, lst, r stlen, call Member Services right away and we will send yu a new card. Sectin 3.2 The Prvider Directry: yur guide t all prviders in the plan s netwrk Every year that yu are a member f ur plan, we will send yu either a new Prvider Directry r an update t yur Prvider Directry. This directry lists ur netwrk prviders. What are netwrk prviders? Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities we have signed cntracts with t deliver certain cvered services t members in ur plan. These prviders have already agreed t see members f ur plan. See Chapter 3, Sectin 1.2 fr infrmatin abut the rules fr getting yur cvered services under ur plan. We have netwrk prviders fr all services cvered under Original Medicare. Yu can still receive cvered services frm ut-f-netwrk prviders (thse wh d nt have a signed cntract with ur plan), as lng as thse prviders agree t accept ur plan s terms and cnditins f payment, as described in Chapter 3, Sectin 1.2.

8 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 5 Why d yu need t knw which prviders are part f ur netwrk? There are several reasns why it is imprtant fr yu t knw whether ur plan uses a netwrk and if s, which prviders are part f the netwrk: A netwrk prvider must furnish yu care while an ut-f-netwrk prvider has the right t refuse t treat yu; A netwrk prvider frequently charges less cst-sharing than an ut-f-netwrk prvider. The amunt f cst sharing yu pay a prvider wh is nt ne f ur netwrk prviders may be mre than the cst sharing yu pay a netwrk prvider. In the plan s Medical Benefits Chart in Chapter 4 f this bklet, we indicate the services fr which the cst-sharing amunt differs between netwrk prviders and utf-netwrk prviders. If ur plan chses t have a netwrk, we must prvide a sufficient number and range f prviders t meet yur needs. These requirements are ver and abve the access standards used by Original Medicare. If yu dn t have yur cpy f the Prvider Directry, yu can request a cpy frm Member Services. Yu may ask Member Services fr mre infrmatin abut ur netwrk prviders, including their qualificatins. Yu can als see the Prvider Directry at r dwnlad it frm this website. Bth Member Services and the website can give yu the mst up-t-date infrmatin abut changes in ur netwrk prviders. Sectin 3.3 The Pharmacy Directry: yur guide t pharmacies in ur netwrk What are netwrk pharmacies? Our Pharmacy Directry gives yu a cmplete list f ur netwrk pharmacies that means all f the pharmacies that have agreed t fill cvered prescriptins fr ur plan members. Why d yu need t knw abut netwrk pharmacies? Yu can use the Pharmacy Directry t find the netwrk pharmacy yu want t use. This is imprtant because, with few exceptins, yu must get yur prescriptins filled at ne f ur netwrk pharmacies if yu want ur plan t cver (help yu pay fr) them. We will send yu a cmplete Pharmacy Directry at least nce every three years. Every year that yu dn t get a new Pharmacy Directry, we ll send yu an update that shws changes t the directry. If yu dn t have the Pharmacy Directry, yu can get a cpy frm Member Services (phne numbers are n the frnt cver). At any time, yu can call Member Services t get up-t-date infrmatin abut changes in the pharmacy netwrk. Yu can als find this infrmatin n ur website at Sectin 3.4 The plan s List f Cvered Drugs (Frmulary) The plan has a List f Cvered Drugs (Frmulary). We call it the Drug List fr shrt. It tells which Part D prescriptin drugs are cvered by Medi-Pak Advantage MA-PD Optin 1 (PFFS). The drugs n this list are

9 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 6 selected by the plan with the help f a team f dctrs and pharmacists. The list must meet requirements set by Medicare. Medicare has apprved the Medi-Pak Advantage MA-PD Optin 1 (PFFS) Drug List. We will send yu a cpy f the Drug List. T get the mst cmplete and current infrmatin abut which drugs are cvered, yu can visit the plan s website ( r call Member Services (phne numbers are n the frnt cver f this bklet). Sectin 3.5 Reprts with a summary f payments made fr yur prescriptin drugs When yu use yur prescriptin drug benefits, we will send yu a reprt t help yu understand and keep track f payments fr yur prescriptin drugs. This summary reprt is called the Explanatin f Benefits. The Explanatin f Benefits tells yu the ttal amunt yu have spent n yur prescriptin drugs and the ttal amunt we have paid fr each f yur prescriptin drugs during the mnth. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut the Explanatin f Benefits and hw it can help yu keep track f yur drug cverage. An Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact Member Services. SECTION 4 Yur mnthly premium fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) Sectin 4.1 Hw much is yur plan premium? As a member f ur plan, yu pay a mnthly plan premium. Fr 2011, the mnthly premium fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) is $ In additin, yu must cntinue t pay yur Medicare Part B premium. In sme situatins, yur plan premium culd be less The Extra Help prgram helps peple with limited resurces pay fr their drugs. Chapter 2, Sectin 7 tells mre abut this prgram. If yu qualify, enrlling in the prgram might make lwer yur mnthly plan premium. If yu are already enrlled and getting help frm ne f these prgrams, sme f the payment infrmatin in this Evidence f Cverage may nt apply t yu. We have included a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs, (LIS Rider) that tells yu abut yur drug cverage. If yu dn t have this insert, please call Member Services and ask fr the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (LIS Rider). Phne numbers fr Member Services are n the frnt cver. In sme situatins, yur plan premium culd be mre In sme situatins, yur plan premium culd be mre than the amunt listed abve in Sectin 4.1. These situatins are described belw.

10 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 7 Mst peple will pay the standard mnthly Part D premium. Hwever, starting January 1, 2011, sme peple will pay a higher premium because f their yearly incme (ver $85,000 fr singles--2010, $170,000 fr married cuples--2010). Fr mre infrmatin abut Part D premiums based n incme, yu can visit n the web r call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu may als call the Scial Security Administratin at TTY users shuld call Sme members are required t pay a late enrllment penalty because they did nt jin a Medicare drug plan when they first became eligible r because they had a cntinuus perid f 63 days r mre when they didn t keep their cverage. Fr these members, the late enrllment penalty is added t the plan s mnthly premium. Their premium amunt will be the mnthly plan premium plus the amunt f their late enrllment penalty. If yu are required t pay the late enrllment penalty, the amunt f yur penalty depends n hw lng yu waited befre yu enrlled in drug cverage r hw many mnths yu were withut drug cverage after yu became eligible. Chapter 6, Sectin 10 explains the late enrllment penalty. If yu have a late enrllment penalty, it is part f yur plan premium. If yu d nt pay the part f yur premium that is the late enrllment penalty, yu culd be disenrlled fr failure t pay yur plan premium. Many members are required t pay ther Medicare premiums As explained in Sectin 2 abve, in rder t be eligible fr ur plan, yu must maintain yur eligibility fr Medicare Parts A and B. Fr that reasn, sme plan members will be paying a premium fr Medicare Part A and mst plan members will be paying a premium fr Medicare Part B, in additin t paying the mnthly plan premium. Yu must cntinue paying yur Medicare Part B premium t remain a member f the plan. Yur cpy f Medicare & Yu 2011 tells abut these premiums in the sectin called 2011 Medicare Csts. This explains hw the Part B premium differs fr peple with different incmes. Everyne with Medicare receives a cpy f Medicare & Yu each year in the fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy f Medicare & Yu 2011 frm the Medicare website ( Or, yu can rder a printed cpy by phne at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users call Sectin 4.2 There are several ways yu can pay yur plan premium There are three ways yu can pay yur plan premium. Call Member Services if yu wish t change yur methd f payment. If yu decide t change the way yu pay yur premium, it can take up t three mnths fr yur new payment methd t take effect. While we are prcessing yur request fr a new payment methd, yu are respnsible fr making sure that yur plan premium is paid n time. Optin 1: Yu can pay by check

11 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 8 Checks shuld be made ut t the plan and sent t the plan. Checks shuld nt be made ut t the Centers fr Medicare & Medicaid Services (CMS) r the U.S. Department f Health and Human Services (HHS) and the checks shuld nt be sent t these agencies. Yu may decide t pay yur mnthly plan premium directly t ur Plan. Medi-Pak Advantage MA-PD Optin 1 (PFFS) will send yu an invice mnthly. Yur payment will be due the 1 st f each mnth. Yur check shuld be made ut t Arkansas Blue Crss Blue Shield and sent t Arkansas Blue Crss and Blue Shield, P.O. Bx , St. Luis, MO Optin 2: Yu can have yur premium taken directly frm yur bank accunt Instead f paying by check, yu can have yur mnthly plan premium autmatically withdrawn frm yur bank accunt. The apprximate day f the mnth the deductin will be made is the 3 rd. In rder t have yur premiums deducted frm yur bank accunt, please cntact Member Services t have the apprpriate frm frwarded t yu. Optin 3: Yu can have the plan premium taken ut f yur mnthly Scial Security check Yu can have the plan premium taken ut f yur mnthly Scial Security check. Cntact Member Services fr mre infrmatin n hw t pay yur mnthly plan premium this way. We will be happy t help yu set this up. What t d if yu are having truble paying yur plan premium Yur plan premium is due in ur ffice by the 1 st day f the Mnth. If we have nt received yur premium by the 1 st day f the Mnth, we will send yu a ntice telling yu that yur plan membership will end if we d nt receive yur premium within 2 mnths. If yu are having truble paying yur premium n time, please cntact Member Services t see if we can direct yu t prgrams that will help with yur plan premium. If we end yur membership with the plan because f nn-payment f premiums, and yu dn t currently have prescriptin drug cverage then yu will nt be able t receive Part D cverage until the annual electin perid. At that time, yu may either jin a stand-alne prescriptin drug plan r a health plan that als prvides drug cverage. If we end yur membership due t nn-payment f premiums, yu will have cverage under Original Medicare. At the time we end yur membership, yu may still we us fr premiums yu have nt paid. In the future, if yu want t enrll again in ur plan (r anther plan that we ffer), yu will need t pay these late premiums befre yu can enrll. Sectin 4.3 Can we change yur mnthly plan premium during the year? N. We are nt allwed t change the amunt we charge fr the plan s mnthly plan premium during the year. If the mnthly plan premium changes fr next year we will tell yu in Octber and the change will take effect n January 1. Hwever, in sme cases the part f the premium that yu have t pay can change during the year. This happens if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year. If a member qualifies fr Extra Help with their prescriptin drug csts, the Extra Help prgram will pay part f the member s mnthly plan premium. S a member wh becmes eligible fr Extra Help during the year wuld begin t pay less tward their mnthly premium. And a member wh lses their eligibility

12 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 9 during the year will need t start paying their full mnthly premium. Yu can find ut mre abut Extra Help in Chapter 2, Sectin 7. SECTION 5 Please keep yur plan membership recrd up t date Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu Yur membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage. The dctrs, hspitals, pharmacists, and ther prviders in the plan s netwrk need t have crrect infrmatin abut yu. These netwrk prviders use yur membership recrd t knw what services and drugs are cvered fr yu. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. Call Member Services t let us knw abut these changes: Changes t yur name, yur address, r yur phne number Changes in any ther health insurance cverage yu have (such as frm yur emplyer, yur spuse s emplyer, wrkers cmpensatin, r Medicaid) If yu have any liability claims, such as claims frm an autmbile accident If yu have been admitted t a nursing hme If yu are participating in a clinical research study Read ver the infrmatin we send yu abut any ther insurance cverage yu have Medicare requires that we cllect infrmatin frm yu abut any ther medical r drug insurance cverage that yu have. That s because we must crdinate any ther cverage yu have with yur benefits under ur plan. Once each year, we will send yu a letter that lists any ther medical and drug insurance cverage that we knw abut. Please read ver this infrmatin carefully. If it is crrect, yu dn t need t d anything. If the infrmatin is incrrect, r if yu have ther cverage that is nt listed, please call Member Services (phne numbers are n the cver f this bklet).

13 Chapter 2: Imprtant phne numbers and resurces 10 Chapter 2. Imprtant phne numbers and resurces SECTION 1 Medi-Pak Advantage MA-PD Optin 1 (PFFS) cntacts (hw t cntact us, including hw t reach Member Services at the plan) 11 SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) 15 SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) 16 SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) 16 SECTION 5 Scial Security 17 SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) 17 SECTION 7 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs 18 SECTION 8 Hw t cntact the Railrad Retirement Bard 19 SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer? 20

14 Chapter 2: Imprtant phne numbers and resurces 11 SECTION 1 Medi-Pak Advantage MA-PD Optin 1 (PFFS) cntacts (hw t cntact us, including hw t reach Member Services at the plan) Fr assistance with claims, billing, r member card questins, please call r write t Medi-Pak Advantage MA- PD Optin 1 (PFFS) Member Services. We will be happy t help yu. Member Services CALL TTY/TDD WRITE WEBSITE (877) Calls t this number are free. Office hurs are Mnday thrugh Friday, 8 a.m. t 8 p.m. (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Office hurs are Mnday thrugh Friday, 8 a.m. t 8 p.m. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss and Blue Shield P O Bx 3835 Scrantn, PA Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care Yu may call us if yu have questins abut ur cverage decisin prcess. Cverage Decisins fr Medical Care CALL TTY WRITE (877) Calls t this number are free. (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR 72203

15 Chapter 2: Imprtant phne numbers and resurces 12 Fr mre infrmatin n asking fr cverage decisins abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making an appeal abut yur medical care Appeals fr Medical Care CALL (877) Calls t this number are free. TTY (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR Fr mre infrmatin n making an appeal abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making a cmplaint abut yur medical care Fr mre infrmatin n making a cmplaint abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Cmplaints abut Medical Care CALL (877) Calls t this number are free. TTY (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free.

16 Chapter 2: Imprtant phne numbers and resurces 13 Cmplaints abut Medical Care WRITE Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR Hw t cntact us when yu are asking fr a cverage decisin abut yur Part D prescriptin drugs Cverage Decisins fr Part D Prescriptin Drugs CALL TTY WRITE Calls t this number are free This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Clinical Department P. O. Bx Phenix, AZ Fr mre infrmatin n asking fr cverage decisins abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making an appeal abut yur Part D prescriptin drugs Appeals fr Part D Prescriptin Drugs ALL TTY Calls t this number are free This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. FAX WRITE Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Clinical Department P. O. Bx Phenix, AZ

17 Chapter 2: Imprtant phne numbers and resurces 14 Fr mre infrmatin n making an appeal abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making a cmplaint abut yur Part D prescriptin drugs Cmplaints abut Part D prescriptin drugs CALL TTY WRITE Calls t this number are free This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Clinical Department P. O. Bx Phenix, AZ Fr mre infrmatin n making a cmplaint abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Where t send a request that asks us t pay fr ur share f the cst fr medical care r drug yu have received Fr mre infrmatin n situatins in which yu may need t ask the plan fr reimbursement r t pay a bill yu have received frm a prvider, see Chapter 7 (Asking the plan t pay its share f a bill yu have received fr medical services r drugs). Please nte: If yu send us a payment request and we deny any part f yur request, yu can appeal ur decisin. See Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) fr mre infrmatin. Payment Requests CALL Calls t this number are free. TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking.

18 Chapter 2: Imprtant phne numbers and resurces 15 Payment Requests WRITE Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) Medicare is the Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with disabilities, and peple with End-Stage Renal Disease (permanent kidney failure requiring dialysis r a kidney transplant). The Federal agency in charge f Medicare is the Centers fr Medicare & Medicaid Services (smetimes called CMS ). This agency cntracts with and regulates Medicare Advantage Organizatins including us. Medicare CALL MEDICARE, r Calls t this number are free. 24 hurs a day, 7 days a week. TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. WEBSITE This is the fficial gvernment website fr Medicare. It gives yu up-t-date infrmatin abut Medicare and current Medicare issues. It als has infrmatin abut hspitals, nursing hmes, physicians, hme health agencies, and dialysis facilities. It includes bklets yu can print directly frm yur cmputer. It has tls t help yu cmpare Medicare Advantage Plans and Medicare drug plans in yur area. Yu can als find Medicare cntacts in yur state by selecting Helpful Phne Numbers and Websites. If yu dn t have a cmputer, yur lcal library r senir center may be able t help yu visit this website using its cmputer. Or, yu can call Medicare at the number abve and tell them what infrmatin yu are lking fr. They will find the infrmatin n the website, print it ut, and send it t yu.

19 Chapter 2: Imprtant phne numbers and resurces 16 SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) The State Health Insurance Assistance Prgram (SHIP) is a gvernment prgram with trained cunselrs in every state. In Arkansas, the State Health Insurance Assistance Prgram is called Arkansas Senir Health Insurance Infrmatin Prgram. Arkansas Senir Health Insurance Infrmatin Prgram is independent (nt cnnected with any insurance cmpany r health plan). It is a state prgram that gets mney frm the Federal gvernment t give free lcal health insurance cunseling t peple with Medicare. Arkansas Senir Health Insurance Infrmatin Prgram cunselrs can help yu with yur Medicare questins r prblems. They can help yu understand yur Medicare rights, help yu make cmplaints abut yur medical care r treatment, and help yu straighten ut prblems with yur Medicare bills. Arkansas Senir Health Insurance Infrmatin Prgram cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans. Arkansas Senir Health Insurance Infrmatin Prgram CALL WRITE 1200 West Third Street Little Rck, AR SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) There is a Quality Imprvement Organizatin in each state. In Arkansas, the Quality Imprvement Organizatin is called Arkansas Fundatin fr Medical Care. Arkansas Fundatin fr Medical Care has a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. Arkansas Fundatin fr Medical Care is an independent rganizatin. It is nt cnnected with ur plan. Yu shuld cntact Arkansas Fundatin fr Medical Care in any f these situatins: Yu have a cmplaint abut the quality f care yu have received. Yu think cverage fr yur hspital stay is ending t sn. Yu think cverage fr yur hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services are ending t sn.

20 Chapter 2: Imprtant phne numbers and resurces 17 Arkansas Fundatin fr Medical Care CALL WRITE SECTION West Capitl Little Rck, AR Scial Security Scial Security is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens wh are 65 r lder, r wh have a disability r end stage renal disease and meets certain cnditins, are eligible fr Medicare. If yu are already getting Scial Security checks, enrllment int Medicare is autmatic. If yu are nt getting Scial Security checks, yu have t enrll in Medicare and pay the Part B premium. Scial Security handles the enrllment prcess fr Medicare. T apply fr Medicare, yu can call the Scial Security r visit yur lcal Scial Security ffice. Scial Security Administratin CALL TTY Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. Yu can use ur autmated telephne services t get recrded infrmatin and cnduct sme business 24 hurs a day This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. WEBSITE SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Medicaid is a jint Federal and state gvernment prgram that helps with medical csts fr certain peple with limited incmes and resurces. Sme peple with Medicare are als eligible fr Medicaid. Medicaid has prgrams that can help pay fr yur Medicare premiums and ther csts, if yu qualify. T find ut mre abut Medicaid and its prgrams, cntact Arkansas Department f Health and Human Services.

21 Chapter 2: Imprtant phne numbers and resurces 18 Arkansas Department f Health and Human Services CALL TTY WRITE SECTION This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. P. O. Bx 1437 Slt 1100 Dnaghey Plaza Suth Little Rck, AR Infrmatin abut prgrams t help peple pay fr their prescriptin drugs Medicare s Extra Help Prgram Medicare prvides Extra Help t pay prescriptin drug csts fr peple wh have limited incme and resurces. Resurces include yur savings and stcks, but nt yur hme r car. If yu qualify, yu get help paying fr any Medicare drug plan s mnthly premium, yearly deductible, and prescriptin cpayments. This Extra Help als cunts tward yur ut-f-pcket csts. Peple with limited incme and resurces may qualify fr Extra Help. Sme peple autmatically qualify fr Extra Help and dn t need t apply. Medicare mails a letter t peple wh autmatically qualify fr Extra Help MEDICARE ( ). TTY users shuld call , 24 hurs a day, 7 days a week; The Scial Security Office at , between 7 am t 7 pm, Mnday thrugh Friday. TTY users shuld call ; r Yur State Medicaid Office. (See Sectin 6 f this chapter fr cntact infrmatin) If yu believe yu have qualify fr Extra Help and yu believe that yu are paying an incrrect cst-sharing amunt when yu get yur prescriptin at a pharmacy, ur plan has established a prcess that allws yu t either request assistance in btaining evidence f yur prper cpayment level, r, if yu already have the evidence, t prvide this evidence t us. Please frward t Medi-Pak Advantage MA-PD Optin 1 (PFFS) a cpy f any f the fllwing dcuments: A cpy f the yur Medicaid card which includes yur name and an eligibility date during the discrepant perid; A reprt f cntact including the date a verificatin call was made t the State Medicaid Agency and the name, title and telephne number f the state staff persn wh verified the Medicaid status during the discrepant perid; A cpy f a state dcument that cnfirms active Medicaid status during the discrepant perid; A print ut frm the State electrnic enrllment file shwing Medicaid status during the discrepant perid;

22 Chapter 2: Imprtant phne numbers and resurces 19 A screen print frm the State s Medicaid systems shwing Medicaid status during the discrepant perid; r Other dcumentatin prvided by the State shwing Medicaid status during the discrepant perid. T establish that yu are institutinalized and qualify fr a zer cst-sharing level, please furnish ne r mre f the fllwing frms f prf: A remittance frm the facility shwing Medicaid payment r a full calendar mnth fr yu during the discrepant perid; A cpy f a state dcumentatin that cnfirms Medicaid payment t the facility fr a full calendar mnth n behalf f yu; r A screen print frm the State s Medicaid system shwing that individual s institutinal status based n at least a full calendar mnth stay fr Medicaid payment purpses during the discrepant perid. Please send a cpy f yur dcuments t: Medi-Pak Advantage MA-PD Optin 1 (PFFS), Arkansas Blue Crss and Blue Shield, P.O. Bx 3835, Scrantn, PA If yu cannt prvide prf f ne f the required dcuments listed abve, yu will need t cntact the plan at The plan will ntify CMS n yur behalf t assist in btaining evidence. When we receive the evidence shwing yur cpayment level, we will update ur system s that yu can pay the crrect cpayment when yu get yur next prescriptin at the pharmacy. If yu verpay yur cpayment, we will reimburse yu. Either we will frward a check t yu in the amunt f yur verpayment r we will ffset future cpayments. If the pharmacy hasn t cllected a cpayment frm yu and is carrying yur cpayment as a debt wed by yu, we may make the payment directly t the pharmacy. If a state paid n yur behalf, we may make payment directly t the state. Please cntact Member Services if yu have questins. Medicare Cverage Gap Discunt Prgram Beginning in 2011, the Medicare Cverage Gap Discunt Prgram will prvide manufacturer discunts n brand name drugs t Part D enrllees wh have reached the cverage gap and are nt already receiving Extra Help. A 50% discunt n the negtiated price (excluding the dispensing fee) will be available fr thse brand name drugs frm manufacturers that have agreed t pay the discunt. We will autmatically apply the discunt when yur pharmacy bills yu fr yur prescriptin and yur Explanatin f Benefits will shw any discunt prvided. The amunt discunted by the manufacturer cunts tward yur ut-f-pckets csts as if yu had paid this amunt and mves yu thrugh the cverage gap. If yu have any questins abut the availability f discunts fr the drugs yu are taking r abut the Medicare Cverage Gap Discunt Prgram in general, please cntact Member Services (phne numbers are n the frnt cver). SECTION 8 Hw t cntact the Railrad Retirement Bard

23 Chapter 2: Imprtant phne numbers and resurces 20 The Railrad Retirement Bard is an independent Federal agency that administers cmprehensive benefit prgrams fr the natin s railrad wrkers and their families. If yu have questins regarding yur benefits frm the Railrad Retirement Bard, cntact the agency. Railrad Retirement Bard CALL TTY WEBSITE Calls t this number are free. Available 9:00 am t 3:30 pm, Mnday thrugh Friday If yu have a tuch-tne telephne, recrded infrmatin and autmated services are available 24 hurs a day, including weekends and hlidays This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are nt free. SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer? If yu (r yur spuse) get benefits frm yur (r yur spuse s) emplyer r retiree grup, call the emplyer/unin benefits administratr r Member Services if yu have any questins. Yu can ask abut yur (r yur spuse s) emplyer r retiree health benefits, premiums, r the enrllment perid. If yu have ther prescriptin drug cverage thrugh yur (r yur spuse s) emplyer r retiree grup, please cntact that grup s benefits administratr. The benefits administratr can help yu determine hw yur current prescriptin drug cverage will wrk with ur plan.

24 Chapter 3: Using the plan s cverage fr yur medical services 21 Chapter 3. Using the plan s cverage fr yur medical services SECTION 1 Things t knw abut getting yur medical care as a member f ur plan 22 Sectin 1.1 What are netwrk prviders and cvered services? 22 Sectin 1.2 Basic rules fr getting yur medical care that is cvered by the plan 22 SECTION 2 Use prviders in the plan s netwrk t get yur medical care 24 Sectin 2.1 Hw t get care frm netwrk prviders 24 SECTION 3 Hw t get cvered services when yu have an emergency 24 Sectin 3.1 Getting care if yu have a medical emergency 24 SECTION 4 What if yu are billed directly fr the full cst f yur cvered services? 25 Sectin 4.1 Yu can ask the plan t pay ur share f the cst f yur cvered services 25 Sectin 4.2 If services are nt cvered by ur plan, yu must pay the full cst 26 SECTION 5 Hw are yur medical services cvered when yu are in a clinical research study? 26 Sectin 5.1 What is a clinical research study? 26 Sectin 5.2 When yu participate in a clinical research study, wh pays fr what? 27 SECTION 6 Rules fr getting care in a religius nn-medical health care institutin 27 Sectin 6.1 What is a religius nn-medical health care institutin? 27 Sectin 6.2 What care frm a religius nn-medical health care institutin is cvered by ur plan? 28

25 Chapter 3: Using the plan s cverage fr yur medical services 22 SECTION 1 Things t knw abut getting yur medical care as a member f ur plan This chapter tells things yu need t knw abut using the plan t get yur medical care cverage. It gives definitins f terms and explains the rules yu will need t fllw t get the medical treatments, services, and ther medical care that are cvered by the plan. Fr the details n what medical care is cvered by ur plan and hw much yu pay as yur share f the cst when yu get this care, use the benefits chart in the next chapter, Chapter 4 (Medical benefits chart, what is cvered and what yu pay). Sectin 1.1 What are netwrk prviders and cvered services Here are sme definitins that can help yu understand hw yu get the care and services that are cvered fr yu as a member f ur plan: Prviders are dctrs and ther health care prfessinals that the state licenses t prvide medical services and care. The term prviders als includes hspitals and ther health care facilities. Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities that we have signed cntracts with t deliver cvered services t members in ur plan. These prviders have already agreed t see members f ur plan. Sectin 1.2 describes the rules fr getting cvered services using ur netwrk prviders. Cvered services include all the medical care, health care services, supplies, and equipment that are cvered by ur plan. Yur cvered services fr medical care are listed in the benefits chart in Chapter 4. Sectin 1.2 Basic rules fr getting yur medical care that is cvered by the plan Medi-Pak Advantage MA-PD Optin 1 (PFFS) will generally cver yur medical care as lng as: The care yu receive is included in the plan s Medical Benefits Chart (this chart is in Chapter 4 f this bklet). The care yu receive is cnsidered medically necessary. It needs t be accepted treatment fr yur medical cnditin. Yu can receive yur care frm any prvider in the United States, if the prvider agrees t accept ur plan s terms and cnditins f payment prir t prviding services t yu and is eligible t prvide services under Original Medicare r eligible t be paid by Medi-Pak Advantage MA-PD Optin 1 (PFFS) fr benefits that are nt cvered under Original Medicare.

26 Chapter 3: Using the plan s cverage fr yur medical services 23 A Medicare Advantage Private Fee-fr-Service plan wrks differently than a Medicare supplement plan. We have netwrk prviders (that is, prviders wh have signed cntracts with ur plan) fr all services cvered under Original Medicare. These prviders have already agreed t see members f ur plan. If yur prvider is nt ne f ur netwrk prviders, then the prvider is nt required t agree t accept the plan s terms and cnditins, f payment, they may chse nt t prvide health care services t yu, except in emergencies. If this happens, yu will need t find anther prvider that will accept ur terms and cnditins f payment. Prviders can find the plan s terms and cnditins f payment n ur website at A prvider is cnsidered t have agreed t accept the terms and cnditins f payment if the prvider was aware that yu are a member f the PFFS plan befre prviding services t yu (fr example: if yu shwed them yur PFFS plan card); the prvider had reasnable access t ur terms and cnditins f payment; and the prvider prvided cvered services t yu. The prvider desn t have t actually read the terms and cnditins f payment - If the prvider had the pprtunity t read them and treats yu, the law deems this prvider t have agreed t accept ur plan s terms and cnditins f payment fr that specific visit. Yu must shw yur plan membership card every time yu visit a prvider. A prvider can decide at every visit whether t accept ur plan s terms and cnditins, and thus treat yu. A prvider cannt change his/her mind abut accepting the terms and cnditins f payment after prviding services. Nt all prviders accept ur plan s terms and cnditins f payment r agree t treat yu. If a prvider frm whm yu seek care decides nt t accept ur plan s terms and cnditins f payment r refuses t treat yu, then yu will need t find anther prvider that will accept ur plan s terms and cnditins f payment. A prvider that decides nt t accept ur plan s terms and cnditins f payment shuld nt prvide services t yu, except in emergencies. Yu may cntact us at (877) fr assistance lcating anther prvider in yur area wh will accept ur plan s terms and cnditins f payment. If yu need emergency care, it is cvered whether a prvider agrees t accept the plan s payment terms r nt. Our plan has signed cntracts with sme prviders t deliver cvered services t members in ur plan. These prviders are ur netwrk prviders. Yu can get a list f these prviders at r yu may call Member Services at the number n the frnt cver f this bklet. We have netwrk prviders fr services cvered under Medicare. Yu can still receive cvered services frm ut-f-netwrk prviders (thse wh d nt have a signed cntract with ur plan), as lng as thse prviders agree t accept ur plan s terms and cnditins f payment, as described earlier in this sectin. Fr services fr which netwrk prviders are nt available, yu can receive cvered services frm any prvider wh agrees t accept ur plan s terms and cnditins f payment, as described earlier in this sectin.

27 Chapter 3: Using the plan s cverage fr yur medical services 24 The amunt f cst sharing yu pay a prvider wh is nt ne f ur netwrk prviders may be mre than the cst sharing yu pay a netwrk prvider. In the plan s Medical Benefits Chart in Chapter 4 f this bklet, we indicate the services fr which the cst-sharing amunt differs between netwrk prviders and ut-f-netwrk prviders. Yu are required t pay nly the cpayment r cinsurance amunt allwed by ur plan at the time f the visit. Yu shuld ask the prvider t bill the plan fr yur cvered services. If prvider asks yu t pay the full amunt f the services, and have yu paid back by the plan, remind the prvider that yu are nly respnsible fr the cst-sharing amunt. If the prvider wants further infrmatin n payment fr cvered services, please have the prvider cntact us at r mail their questins t Arkansas Blue Crss Blue Shield, Medi-Pak Advantage (PFFS), P.O. Bx 2181, Little Rck, AR Medi-Pak Advantage MA-PD Optin 1 (PFFS) des nt require members r their prviders t btain prir authrizatin r a referral frm the plan as a cnditin fr cvering medically necessary services that are cvered by ur plan. Under prir authrizatin, a plan requires members r prviders t seek authrizatin frm the plan prir t btaining services. There is n such requirement fr ur members. Our plan als des nt have any prir ntificatin rules. Under prir ntificatin, a plan charges members lwer cst sharing amunts fr sme services if members r their prviders ntify the plan befre the member receives the service. If yu have any questins abut whether we will pay fr any medical service r care that yu are cnsidering, yu have the right t ask us whether we will cver it befre yu get it. Sectin 2 Sectin 2.1 Use prviders in the plan s netwrk t get yur medical care Hw t get care frm netwrk prviders A specialist is a dctr wh prvides health care services fr a specific disease r part f the bdy. There are many kinds f specialists. Here are a few examples: Onclgists, wh care fr patients with cancer. Cardilgists, wh care fr patients with heart cnditins. Orthpedists, wh care fr patients with certain bne, jint, r muscle cnditins. What if a netwrk prvider leaves ur plan? Smetimes a specialist, clinic, hspital r ther netwrk prvider yu are using might leave the plan. Yu can cntinue t see these dctrs and hspitals as lng as they agree t accept ur terms and cnditins; hwever, yu will have t pay a higher cst share. If yu need infrmatin abut in-netwrk dctrs and hspitals in yur area, yu can get a listing n ur website at arkansasbluecrss.cm r call Member Services at number listed n the frnt cver f this bklet. SECTION 3 Sectin 3.1 Hw t get cvered services when yu have an emergency Getting care if yu have a medical emergency What is a medical emergency and what shuld yu d if yu have ne?

28 Chapter 3: Using the plan s cverage fr yur medical services 25 When yu have a medical emergency, yu believe that yur health is in serius danger. A medical emergency can include severe pain, a bad injury, a sudden illness, r a medical cnditin that is quickly getting much wrse. If yu have a medical emergency: Get help as quickly as pssible. Call 911 fr help r g t the nearest emergency rm, hspital, r urgent care center. Call fr an ambulance if yu need it. Yu d nt need t get apprval frm ur plan. What is cvered if yu have a medical emergency? Yu may get cvered emergency medical care whenever yu need it, anywhere in the United States r its territries. Our plan cvers ambulance services in situatins where getting t the emergency rm in any ther way culd endanger yur health. Fr mre infrmatin, see the Medical Benefits Chart in Chapter 4 f this bklet. If yu have an emergency, we will talk with the dctrs wh are giving yu emergency care t help manage and fllw up n yur care. The dctrs wh are giving yu emergency care will decide when yur cnditin is stable and the medical emergency is ver. After the emergency is ver yu are entitled t fllw-up care t be sure yur cnditin cntinues t be stable. If yu decide t get fllw-up care frm the prvider treating yu, then yu shuld advise them f yur plan enrllment as sn as pssible, by shwing them yur membership ID card. The plan will pay fr all medicallynecessary plan-cvered services furnished by the prvider and nn-emergency care that yu get frm any prvider in the United States wh agrees t accept ur plan s terms and cnditins f payment and is eligible t prvide services under Original Medicare. What if it wasn t a medical emergency? Smetimes it can be hard t knw if yu have a medical emergency. Fr example, yu might g in fr emergency care thinking that yur health is in serius danger and the dctr may say that it wasn t a medical emergency after all. If it turns ut that it was nt an emergency, as lng as yu reasnably thught yur health was in serius danger, we will cver yur care. SECTION 4 Sectin 4.1 What if yu are billed directly fr the full cst f yur cvered services? Yu can ask the plan t pay ur share f the cst f yur cvered services In limited instances, yu may be asked t pay the full cst f the service. Other times, yu may find that yu have paid mre than yu expected under the cverage rules f the plan. In either case, yu will want ur plan t pay ur share f the csts by reimbursing yu fr payments yu have already made. There may als be times when yu get a bill frm a prvider fr the full cst f medical care yu have received. In many cases, yu shuld send this bill t us s that we can pay ur share f the csts fr yur cvered medical services.

29 Chapter 3: Using the plan s cverage fr yur medical services 26 If yu have paid mre than yur share fr cvered services, r if yu have received a bill fr the full cst f cvered medical services, g t Chapter 7 (Asking the plan t pay its share f a bill yu have received fr medical services r drugs) fr infrmatin abut what t d. Sectin 4.2 If services are nt cvered by ur plan, yu must pay the full cst Medi-Pak Advantage MA-PD Optin 1 (PFFS) cvers all medical services that are medically necessary, are cvered under Medicare, and are btained cnsistent with plan rules. Yu are respnsible fr paying the full cst f services that aren t cvered by ur plan. If yu have any questins abut whether we will pay fr any medical service r care that yu are cnsidering, yu have the right t ask us whether we will cver it befre yu get it. If we say we will nt cver yur services, yu have the right t appeal ur decisin nt t cver yur care. Chapter 9 (What t d if yu have a prblem r cmplaint) has mre infrmatin abut what t d if yu want a cverage decisin frm us r want t appeal a decisin we have already made. Yu may als call Member Services at the number n the frnt cver f this bklet t get mre infrmatin abut hw t d this. Fr cvered services that have a benefit limitatin, yu pay the full cst f any services yu get after yu have used up yur benefit fr that type f cvered service. This additinal cst will nt cunt tward yur yearly utf-pcket maximum. Yu can call Member Services when yu want t knw hw much f yur benefit limit yu have already used. SECTION 5 Sectin 5.1 Hw are yur medical services cvered when yu are in a clinical research study What is a clinical research study A clinical research study is a way that dctrs and scientists test new types f medical care, like hw well a new cancer drug wrks. They test new medical care prcedures r drugs by asking fr vlunteers t help with the study. This kind f study is ne f the final stages f a research prcess that helps dctrs and scientists see if a new apprach wrks and if it is safe. Nt all clinical research studies are pen t members f ur plan. Medicare first needs t apprve the research study. If yu participate in a study that Medicare has nt apprved, yu will be respnsible fr paying all csts fr yur participatin in the study. Once Medicare apprves the study, smene wh wrks n the study will cntact yu t explain mre abut the study and see if yu meet the requirements set by the scientists wh are running the study. Yu can participate in the study as lng as yu meet the requirements fr the study and yu have a full understanding and acceptance f what is invlved if yu participate in the study. If yu participate in a Medicare-apprved study, Original Medicare pays mst f the csts fr the cvered services yu receive as part f the study. When yu are in a clinical research study, yu may stay enrlled in ur plan and cntinue t get the rest f yur care (the care that is nt related t the study) thrugh ur plan. If yu want t participate in a Medicare-apprved clinical research study, yu d nt need t get apprval frm ur plan r yur PCP. The prviders that deliver yur care as part f the clinical research study d nt need t be part f ur plan s netwrk f prviders. Althugh yu d nt need t get ur plan s permissin t be in a clinical research study, yu d need t tell us befre yu start participating in a clinical research study. Here is why yu need t tell us:

30 Chapter 3: Using the plan s cverage fr yur medical services We can let yu knw whether the clinical research study is Medicare-apprved. 2. We can tell yu what services yu will get frm clinical research study prviders instead f frm ur plan. 3. We can keep track f the health care services that yu receive as part f the study. If yu plan n participating in a clinical research study, cntact Member Services (see Chapter 2, Sectin 1 f this Evidence f Cverage). Sectin 5.2 When yu participate in a clinical research study, wh pays fr what? Once yu jin a Medicare-apprved clinical research study, yu are cvered fr rutine items and services yu receive as part f the study, including: Rm and bard fr a hspital stay that Medicare wuld pay fr even if yu weren t in a study. An peratin r ther medical prcedure if it is part f the research study. Treatment f side effects and cmplicatins f the new care. Original Medicare pays mst f the cst f the cvered services yu receive as part f the study. After Medicare has paid its share f the cst fr these services, ur plan will als pay fr part f the csts. We will pay the difference between the cst-sharing in Original Medicare and yur cst-sharing as a member f ur plan. This means yur csts fr the services yu receive as part f the study will nt be higher than they wuld be if yu received these services utside f a clinical research study. When yu are part f a clinical research study, neither Medicare nr ur plan will pay fr any f the fllwing: Generally, Medicare will nt pay fr the new item r service that the study is testing unless Medicare wuld cver the item r service even if yu were nt in a study. Items and services the study gives yu r any participant fr free. Items r services prvided nly t cllect data, and nt used in yur direct health care. Fr example, Medicare wuld nt pay fr mnthly CT scans dne as part f the study if yur cnditin wuld usually require nly ne CT scan. D yu want t knw mre? T find ut what yur cinsurance wuld be if yu jined a Medicare-apprved clinical research study, please call us at Member Services (phne numbers are n the cver f this bklet). Yu can get mre infrmatin abut jining a clinical research study by reading the publicatin Medicare and Clinical Research Studies n the Medicare website ( Yu can als call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call SECTION 6 Sectin 6.1 Rules fr getting care in a religius nn-medical health care institutin What is a religius nn-medical health care institutin?

31 Chapter 3: Using the plan s cverage fr yur medical services 28 A religius nn-medical health care institutin is a facility that prvides care fr a cnditin that wuld rdinarily be treated in a hspital r skilled nursing facility care. If getting care in a hspital r a skilled nursing facility is against a member s religius beliefs, yu must elect t have yur cverage fr care in a religius nnmedical health care institutin. Yu may chse t pursue medical care at any time fr any reasn. This benefit is prvided nly fr Part A inpatient services (nn-medical health care services). Medicare will nly pay fr nn-medical health care services prvided by religius nn-medical health care institutins. Sectin 6.2 What care frm a religius nn-medical health care institutin is cvered by ur plan? T get care frm a religius nn-medical health care institutin, yu must sign a legal dcument that says yu are cnscientiusly ppsed t getting medical treatment that is nn-excepted. Nn-excepted medical care r treatment is any medical care r treatment that is vluntary and nt required by any federal, state, r lcal law. Excepted medical treatment is medical care r treatment that yu get that is nt vluntary r is required under federal, state, r lcal law. T be cvered by ur plan, the care yu get frm a religius nn-medical health care institutin must meet the fllwing cnditins: The facility prviding the care must be certified by Medicare. Our plan s cverage f services yu receive is limited t nn-religius aspects f care. If yu get services frm this institutin that are prvided t yu in yur hme, ur plan will cver these services nly if yur cnditin wuld rdinarily meet the cnditins fr cverage f services given by hme health agencies that are nt religius nn-medical health care institutins. If yu get services frm this institutin that are prvided t yu in a facility, the fllwing cnditin applies. Yu must have a medical cnditin that wuld allw yu t receive cvered services fr inpatient hspital care r skilled nursing facility care. Care in these facilities will have the same cverage limits as any ther inpatient hspital stay. See the benefits chart in Chapter 4 fr mre infrmatin.

32 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 29 Chapter 4. Medical benefits chart (what is cvered and what yu pay) SECTION 1 Understanding yur ut-f-pcket csts fr cvered services 30 Sectin 1.1 What types f ut-f-pcket csts d yu pay fr yur cvered services? 30 Sectin 1.2 What is the maximum amunt yu will pay fr Medicare Part A and Part B cvered medical services? 30 Sectin 1.3 Hw des balance billing affect yur csts? 30 SECTION 2 Use this Medical Benefits Chart t find ut what is cvered fr yu and hw much yu will pay 31 Sectin 2.1 Yur medical benefits and csts as a member f the plan 31 SECTION 3 What types f benefits are nt cvered by the plan? 46 Sectin 3.1 Types f benefits we d nt cver (exclusins) 46

33 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 30 SECTION 1 Understanding yur ut-f-pcket csts fr cvered services This chapter fcuses n yur cvered services and what yu pay fr yur medical benefits. It includes a Medical Benefits Chart that gives a list f yur cvered services and tells hw much yu will pay fr each cvered service as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS). Later in this chapter, yu can find infrmatin abut medical services that are nt cvered. It als tells abut limitatins n certain services. Sectin 1.1 What types f ut-f-pcket csts d yu pay fr yur cvered services? T understand the payment infrmatin we give yu in this chapter, yu need t knw abut the types f ut-fpcket csts yu may pay fr yur cvered services. The deductible means the amunt yu must pay fr medical services befre ur plan begins t pay its share. A cpayment means that yu pay a fixed amunt each time yu receive a medical service. Yu pay a cpayment at the time yu get the medical service. Cinsurance means that yu pay a percent f the ttal cst f a medical service. Yu pay a cinsurance at the time yu get the medical service. Medi-Pak Advantage MA-PD Optin 1 (PFFS) des nt allw prviders wh prvide plan-cvered services t balance bill members f ur plan. (Fr mre infrmatin, see Sectin 1.3 f this chapter.) Sme peple qualify fr State Medicaid prgrams t help them pay their ut-f-pcket csts fr Medicare. If yu are enrlled in ne f these prgrams, yu may still have t pay a cpayment fr the service, depending n the rules in yur state. Sectin 1.2 What is the maximum amunt yu will pay fr Medicare Part A and Part B cvered medical services? Because yu are enrlled in a Medicare Advantage plan, there is a limit t hw much yu have t pay ut-fpcket each year fr medical services that are cvered under Medicare Part A and Part B (see the Medical Benefits Chart in Sectin 2, belw). As a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS), the mst yu will have t pay ut-f-pcket fr cvered Part A and Part B services in 2011 is $6,700. (The amunt yu pay fr yur plan premium des nt cunt tward yur ut-f-pcket maximum.) If yu reach the maximum ut-f-pcket payment amunt f $6,700, yu will nt have t pay any ut-f-pcket csts fr the remainder f the year fr cvered Part A and Part B services. Yu will have t cntinue t pay yur plan premium and the Medicare Part B premium. Sectin 1.3 Hw des balance billing affect yur csts? Our plan des nt allw balance billing. This means a prvider may cllect nly the plan cst-sharing amunts frm ur members and may nt therwise charge r bill members fr services. Balance billing is prhibited by prviders wh prvide plan-cvered services t Medi-Pak Advantage MA-PD Optin 1 (PFFS) members.

34 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 31 SECTION 2 Use this Medical Benefits Chart t find ut what is cvered fr yu and hw much yu will pay Sectin 2.1 Yur medical benefits and csts as a member f the plan The Medical Benefits Chart n the fllwing pages lists the services Medi-Pak Advantage MA-PD Optin 1 (PFFS) cvers and what yu pay ut-f-pcket fr each service. The services listed in the Medical Benefits Chart are cvered nly when the fllwing cverage requirements are met: Yur Medicare cvered services must be prvided accrding t the cverage guidelines established by Medicare. Except in the case f preventive services and screening tests, yur services (including medical care, services, supplies, and equipment) must be medically necessary. Medically necessary means that the services are used fr the diagnsis, direct care, and treatment f yur medical cnditin and are nt prvided mainly fr yur cnvenience r that f yur dctr. N prir authrizatin, prir ntificatin, r referral is required as a cnditin f cverage when medically necessary, plan-cvered services are prvided t ur members. Our plan cvers all Medicare-cvered preventive services at n cst t yu. Services that are cvered fr yu What yu must pay when yu get these services Inpatient Care Inpatient hspital care Cvered services include: Semi-private rm (r a private rm if medically necessary) Meals including special diets Regular nursing services Csts f special care units (such as intensive/crnary care units) Drugs and medicatins Lab tests X-rays and ther radilgy services Necessary surgical and medical supplies Use f appliances, such as wheelchairs Operating and recvery rm csts Physical, ccupatinal, and speech language therapy Under certain cnditins, the fllwing types f In-Netwrk Days 1-6: $265 cpay per day Days 7-90: $0 cpay per day $0 cpay fr additinal hspital days N limit t the number f days cvered by the plan each benefit perid. Out-f-Netwrk 30% f the cst fr each cvered hspital stay. If yu get inpatient care at a nnplan hspital after yur emergency cnditin is stabilized, yur cst is the cst-sharing yu wuld pay at a netwrk hspital.

35 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 32 Services that are cvered fr yu What yu must pay when yu get these services transplants are cvered: crneal, kidney, kidneypancreatic, heart, liver, lung, heart/lung, bne marrw, stem cell, and intestinal/multivisceral. Bld - including strage and administratin. Cverage f whle bld and packed red cells begins nly with the furth pint f bld that yu need - yu pay fr the first 3 pints f unreplaced bld. All ther cmpnents f bld are cvered beginning with the first pint used. Physician services A benefit perid starts the day yu g int a hspital r skilled nursing facility. It ends when yu g fr 60 days in a rw withut hspital r skilled nursing care. If yu g int the hspital after ne benefit perid has ended, a new benefit begins. There is n limit t the number f benefit perids yu can have. Inpatient mental health care Cvered services include mental health care services that require a hspital stay. List days cvered, restrictins such as 190-day lifetime limit fr inpatient services in a psychiatric hspital. The 190-day limit des nt apply t Mental Health services prvided in a psychiatric unit f a general hspital. In-Netwrk Fr Medicare-cvered hspital stays: Days 1-6: $265 cpay per day Days 7-90: $0 cpay per day $0 cpay fr additinal hspital days Out-f-Netwrk 30% f the cst fr each cvered hspital stay. Skilled nursing facility (SNF) care (Fr a definitin f skilled nursing facility, see Chapter 12 f this bklet. Skilled nursing facilities are smetimes called SNFs. ) Limited t 100 days per benefit perid. A "benefit perid" starts the day yu g int a hspital r skilled nursing facility. It ends when yu g fr 60 days in a rw withut hspital r skilled nursing care. If yu g int the hspital after ne benefit perid has ended, a new benefit perid begins. There is n limit t the number f benefit perids yu can have. N prir hspital stay is required. In-Netwrk Days 1-20: $0 cpay per day Days : $ cpay per day $0 cpay fr additinal hspital days

36 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 33 Cvered services include: Semiprivate rm (r a private rm if medically necessary) Meals, including special diets Regular nursing services Physical therapy, ccupatinal therapy, and speech therapy Drugs administered t yu as part f yur plan f care (This includes substances that are naturally present in the bdy, such as bld cltting factrs.) Bld - including strage and administratin. Cverage f whle bld and packed red cells begins nly with the furth pint f bld that yu need - yu pay fr the first 3 pints f unreplaced bld. All ther cmpnents f bld are cvered beginning with the first pint used. Medical and surgical supplies rdinarily prvided by SNFs Labratry tests rdinarily prvided by SNFs X-rays and ther radilgy services rdinarily prvided by SNFs Use f appliances such as wheelchairs rdinarily prvided by SNFs Physician services Inpatient services cvered when the hspital r SNF days aren t, r are n lnger, cvered Cvered services include: Physician services Tests (like X-ray r lab tests) X-ray, radium, and istpe therapy including technician materials and services Surgical dressings, splints, casts and ther devices used t reduce fractures and dislcatins Prsthetics and rthtics devices (ther than dental) that replace all r part f an internal bdy rgan (including cntiguus tissue), r all r part f the functin f a permanently inperative r malfunctining internal bdy rgan, including replacement r repairs f such devices Leg, arm, back, and neck braces; trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because f breakage, wear, lss, r a change in the patient s physical cnditin Out-f-Netwrk 30% f the cst fr each cvered SNF stay In-Netwrk There is n cpay fr Medicare cvered services Out-f-Netwrk 30% f the cst fr Medicare cvered services

37 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 34 Physical therapy, speech therapy, and ccupatinal therapy Hme health agency care Cvered services include: Part-time r intermittent skilled nursing and hme health aide services (T be cvered under the hme health care benefit, yur skilled nursing and hme health aide services cmbined must ttal fewer than 8 hurs per day and 35 hurs per week) Physical therapy, ccupatinal therapy, and speech therapy Medical scial services Hspice care Yu may receive care frm any Medicare-certified hspice prgram. Original Medicare (rather than ur Plan) will pay the hspice prvider fr the services yu receive. Yur hspice dctr can be a netwrk prvider r an ut-fnetwrk prvider. Yu may still be a plan member and will cntinue t get the rest f yur care that is unrelated t yur terminal cnditin thrugh ur Plan. Hwever, Original Medicare will pay fr yur Part A and Part B services. Yur prvider will bill Original Medicare while yur hspice electin is in frce. Cvered services include: Drugs fr symptm cntrl and pain relief, shrtterm respite care, and ther services nt therwise cvered by Original Medicare Hme care In-Netwrk $0 cpay fr Medicare-cvered hme health visits. Out-f-Netwrk 30% f the cst fr Medicare cvered services When yu enrll in a Medicarecertified hspice prgram, yur hspice services and yur Original Medicare services are paid fr by Original Medicare, nt Medi-Pak Advantage MA-PD Optin 1 (PFFS). Outpatient Services Physician services, including dctr s ffice visits Cvered services include: Office visits, including medical and surgical care in a physician s ffice Medical r surgical services furnished in a certified ambulatry surgical center r in a hspital utpatient setting Cnsultatin, diagnsis, and treatment by a specialist Hearing and balance exams, if yur dctr rders In-Netwrk $15 cpay fr each primary care dctr visit fr Medicare-cvered benefits $35 cpay fr each specialist visit fr Medicare cvered benefits. Out-f-Netwrk

38 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 35 it t see if yu need medical treatment Telehealth ffice visits including cnsultatin, diagnsis and treatment by a specialist Secnd pinin prir t surgery Outpatient hspital services Nn-rutine dental care (cvered services are limited t surgery f the jaw r related structures, setting fractures f the jaw r facial bnes, extractin f teeth t prepare the jaw fr radiatin treatments f neplastic cancer disease, r services that wuld be cvered when prvided by a physician) 30% fr each Medicare-cvered primary care dctr visit. 30% fr each Medicare-cvered specialist visit. Physician Services in an utpatient hspital r ambulatry surgery center In-Netwrk There is n cpay fr Medicare cvered services. Out-f-Netwrk 30% fr Medicare cvered services. Chirpractic services Cvered services include: Manual manipulatin f the spine t crrect subluxatin Pdiatry services Cvered services include: Treatment f injuries and diseases f the feet (such as hammer te r heel spurs). Rutine ft care fr members with certain medical cnditins affecting the lwer limbs Outpatient mental health care Cvered services include: Mental health services prvided by a dctr, clinical psychlgist, clinical scial wrker, clinical nurse specialist, nurse practitiner, physician assistant, r ther Medicare-qualified mental health care prfessinal as allwed under applicable state laws. In-Netwrk $20 cpay fr each Medicarecvered visit. Out-f-Netwrk 30% fr each Medicare-cvered visit. In-Netwrk $20 cpay fr each Medicarecvered visit. Out-f-Netwrk 30% fr each Medicare-cvered visit. In-Netwrk $35 cpay fr each Medicarecvered individual r grup therapy visit. Out-f-Netwrk 30% fr each Medicare-cvered individual r grup therapy visit.

39 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 36 Partial hspitalizatin services Partial hspitalizatin is a structured prgram f active psychiatric treatment that is mre intense than the care received in yur dctr s r therapist s ffice and is an alternative t inpatient hspitalizatin. Outpatient substance abuse services In-Netwrk $250 cpay fr each Medicarecvered partial hspitalizatin visit. Out-f-Netwrk 30% fr each Medicare-cvered partial hspitalizatin visit. In-Netwrk $35 cpay fr each Medicarecvered individual r grup visit. Out-f-Netwrk 30% f the cst fr Medicarecvered utpatient substance abuse benefits. Outpatient surgery, including services prvided at hspital facilities and ambulatry surgical centers In-Netwrk $250 cpay fr each Medicarecvered ambulatry surgical center visit. $250 cpay fr each Medicarecvered utpatient hspital facility visit. Out-f-Netwrk 30% f the cst fr each Medicarecvered ambulatry surgical center visit. 30% f the cst fr each Medicarecvered utpatient hspital facility visit. Ambulance services Cvered ambulance services include fixed wing, rtary wing, and grund ambulance services, t the nearest apprpriate facility that can prvide care nly if they are furnished t a member whse medical cnditin is such that ther means f transprtatin are cntraindicated (culd endanger the persn s health). The member s cnditin must require bth the ambulance transprtatin itself and the level f service prvided in rder fr the billed service t be cnsidered medically necessary. In-Netwrk $250 cpay fr Medicare-cvered ne-way grund ambulance trip. $500 cpay fr Medicare-cvered ne-way air ambulance trip. Out-f-Netwrk $250 cpay fr Medicare-cvered ne-way grund ambulance trip. $500 cpay fr Medicare-cvered ne-way air ambulance trip.

40 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 37 Nn-emergency transprtatin by ambulance is apprpriate if it is dcumented that the member s cnditin is such that ther means f transprtatin are cntraindicated (culd endanger the persn s health) and that transprtatin by ambulance is medically required. Emergency care Services in the U.S. $50 cpay fr Medicare-cvered emergency rm visits in the U.S. If yu are immediately admitted t the hspital, yu pay $0 cpay fr the emergency rm visit. If yu are admitted t the hspital within 1-day fr the same cnditin, yu pay $0 cpay fr the emergency rm visit. If yu need inpatient care at an utf-netwrk hspital after yur emergency cnditin is stabilized, yu wuld pay the in-netwrk cstshare amunt. Services utside the U.S. $250 cpay deductible, then 20% cinsurance up t a maximum f $15,000 plan payment each year fr emergency rm care received utside the cuntry. These ut-f-pcket csts d nt cunt tward the ut-f-pcket maximum. Outpatient rehabilitatin services Cvered services include: physical therapy, ccupatinal therapy, speech language therapy, cardiac rehabilitative services, intensive cardiac rehabilitatin services, pulmnary rehabilitatin services, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services. In-Netwrk $35 cpay fr Medicare-cvered Occupatinal Therapy visits. $35 cpay fr Medicare-cvered Physical and/r Speech/Language Therapy visits. Out-f-Netwrk 30% f the cst fr Medicarecvered Occupatinal Therapy

41 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 38 benefits. 30% f the cst fr Medicarecvered Physical and/r Speech/Language Therapy visits. Durable medical equipment and related supplies (Fr a definitin f durable medical equipment, see Chapter 12 f this bklet.) Cvered items include, but are nt limited t: wheelchairs, crutches, hspital bed, IV infusin pump, xygen equipment, nebulizer, and walker. In-Netwrk 20% f the cst fr Medicarecvered items. Out-f-Netwrk 30% f the cst fr Medicarecvered durable medical equipment. Prsthetic devices and related supplies Devices (ther than dental) that replace a bdy part r functin. These include, but are nt limited t: clstmy bags and supplies directly related t clstmy care, pacemakers, braces, prsthetic shes, artificial limbs, and breast prstheses (including a surgical brassiere after a mastectmy). Includes certain supplies related t prsthetic devices, and repair and/r replacement f prsthetic devices. Als includes sme cverage fllwing cataract remval r cataract surgery see Visin Care later in this sectin fr mre detail. In-Netwrk 20% f the cst fr Medicarecvered items. Out-f-Netwrk 30% f the cst fr Medicarecvered prsthetic devices and related supplies. Diabetes self-mnitring, training, and supplies Fr all peple wh have diabetes (insulin and nn-insulin users). Cvered services include: Bld glucse mnitr, bld glucse test strips, lancet devices and lancets, and glucse-cntrl slutins fr checking the accuracy f test strips and mnitrs Fr peple with diabetes wh have severe diabetic ft disease: One pair per calendar year f therapeutic custm-mlded shes (including inserts prvided with such shes) and tw additinal pairs f inserts, r ne pair f depth shes and three pairs f inserts (nt including the nn-custmized remvable inserts prvided with such shes). Cverage includes fitting. Self-management training is cvered under certain cnditins Fr persns at risk f diabetes: Fasting plasma In-Netwrk $0 cpay fr Diabetes selfmnitring training. 20% f the cst f Diabetes supplies. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicarecvered Diabetes self-mnitring training. 30% f the cst fr Medicarecvered Diabetes supplies.

42 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 39 glucse tests. Tw screenings per year if diagnsed with pre-diabetes. One per year if previusly tested but nt diagnsed r if never tested. Medical nutritin therapy Fr peple with diabetes, renal (kidney) disease (but nt n dialysis), and after a transplant when referred by yur dctr. In-Netwrk $0 cpay fr Nutritin Therapy fr Diabetes r renal disease. Out-f-Netwrk 30% f the cst fr Medicarecvered Nutritin Therapy fr Diabetes r renal disease. Kidney Disease Educatin Services Educatin t teach kidney care and help members make infrmed decisins abut their care. Fr peple with stage IV chrnic kidney disease, when referred by their dctr, we cver up t six sessins f kidney disease educatin services per lifetime. Outpatient diagnstic tests and therapeutic services and supplies Cvered services include: X-rays Radiatin therapy Surgical supplies, such as dressings Supplies, such as splints and casts Labratry tests Bld. Cverage begins with the furth pint f bld that yu need yu pay fr the first 3 pints f unreplaced bld. Cverage f strage and administratin begins with the first pint f bld that yu need. Other utpatient diagnstic tests In-Netwrk $0 cpay fr Medicare-cvered Kidney Disease Educatin services. Out-f-Netwrk 30% f the cst fr Medicarecvered Kidney Disease Educatin services. In-Netwrk $0 cpay fr Medicare cvered: -lab services -diagnstic prcedures and tests $0 cpay fr Medicare-cvered X- rays. $250 cpay fr Medicare-cvered advanced imaging. $0 cpay fr all ther Medicarecvered diagnstic radilgy services. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicare-

43 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 40 cvered diagnstic prcedures, tests, and lab services. 30% f the cst fr Medicarecvered therapeutic radilgy services. 30% f the cst fr Medicarecvered utpatient xrays. 30% f the cst fr Medicarecvered diagnstic radilgy services. Visin care Cvered services include: Outpatient physician services fr eye care. Fr peple wh are at high risk f glaucma, such as peple with a family histry f glaucma, peple with diabetes, and African-Americans wh are age 50 and lder: glaucma screening nce per year One pair f eyeglasses r cntact lenses after each cataract surgery that includes insertin f an intracular lens. Crrective lenses/frames (and replacements) needed after a cataract remval withut a lens implant. Nn-Medicare-cvered eye exams and glasses nt cvered. In-Netwrk $35 cpay fr ne pair f eyeglasses r cntact lenses after cataract surgery. $35 cpay fr exams t diagnse and treat diseases and cnditins f the eye. Out-f-Netwrk 30% f the cst fr Medicarecvered eye exams. 30% f the cst fr Medicarecvered eye wear. Preventive Care and Screening Tests Abdminal artic aneurysm screening A ne-time screening ultrasund fr peple at risk. The plan nly cvers this screening if yu get a referral fr it as a result f yur Welcme t Medicare physical exam. In-Netwrk $0 cpay fr Medicare-cvered abdminal artic aneurysm screening. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicarecvered abdminal artic aneurysm

44 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 41 screening. Bne mass measurement Fr qualified individuals (generally, this means peple at risk f lsing bne mass r at risk f steprsis), the fllwing services are cvered every 2 years r mre frequently if medically necessary: prcedures t identify bne mass, detect bne lss, r determine bne quality, including a physician s interpretatin f the results. In-Netwrk $0 cpay fr Medicare-cvered bne mass measurement Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicarecvered bne mass measurement. Clrectal screening Fr peple 50 and lder, the fllwing are cvered: Flexible sigmidscpy (r screening barium enema as an alternative) every 48 mnths Fecal ccult bld test, every 12 mnths Fr peple at high risk f clrectal cancer, we cver: Screening clnscpy (r screening barium enema as an alternative) every 24 mnths Fr peple nt at high risk f clrectal cancer, we cver: Screening clnscpy every 10 years, but nt within 48 mnths f a screening sigmidscpy In-Netwrk $0 cpay fr Medicare-cvered clrectal screenings. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicarecvered clrectal screenings. HIV screening Fr peple wh ask fr an HIV screening test r wh are at increased risk fr HIV infectin, we cver: One screening exam every 12 mnths Fr wmen wh are pregnant, we cver: Up t three screening exams during a pregnancy $0 cpay fr Medicare-cvered HIV screenings. Immunizatins Cvered services include: Pneumnia vaccine Flu shts, nce a year in the fall r winter Hepatitis B vaccine if yu are at high r $0 cpay fr Flu and Pneumnia vaccines. $0 cpay fr Hepatitis B vaccine.

45 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 42 intermediate risk f getting Hepatitis B Other vaccines if yu are at risk We als cver sme vaccines under ur utpatient prescriptin drug benefit. Mammgraphy screening Cvered services include: One baseline exam between the ages f 35 and 39 One screening every 12 mnths fr wmen age 40 and lder In-Netwrk $0 cpay fr Medicare-cvered screening mammgrams. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicarecvered screening mammgrams. Pap test, pelvic exams, and clinical breast exams Cvered services include: Fr all wmen, Pap tests, pelvic exams, and clinical breast exams are cvered nce every 24 mnths If yu are at high risk f cervical cancer r have had an abnrmal Pap test and are f childbearing age: ne Pap test every 12 mnths In-Netwrk $0 cpay fr Medicare-cvered pap smears and pelvic exams. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Out-f-Netwrk 30% f the cst fr Medicarecvered pap smears and pelvic exams. Prstate cancer screening exams Fr men age 50 and lder, cvered services include the fllwing - nce every 12 mnths: Digital rectal exam Prstate Specific Antigen (PSA) test In-Netwrk $0 cpay fr Medicare-cvered prstate cancer screening Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is

46 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 43 billed. Out-f-Netwrk 30% f the cst fr Medicarecvered prstate cancer screening. Cardivascular disease testing Bld tests fr the detectin f cardivascular disease (r abnrmalities assciated with an elevated risk f cardivascular disease). Cvered nce every five years. In-Netwrk $0 cpay fr Medicare-cvered cardivascular disease testing. Separate Office Visit cst sharing f $15 cpay fr a primary care physician visit r $35 cpay fr a specialist ffice visit may apply, if a separate ffice visit service is billed. Physical Exam (Welcme t Medicare Physical Exam) A physical exam fr members that have Medicare Part B. Includes measurement f height, weight, bdy mass index, bld pressure, visual acuity screen and ther rutine measurements; an electrcardigram; educatin, cunseling and referral with respect t cvered screening and preventive services. Desn t include lab tests. Out-f-Netwrk 30% f the cst fr Medicarecvered cardivascular disease testing. Limited t 1 exam(s) every year. In-Netwrk $0 cpay fr rutine exams. Out-f-Netwrk 30% f the cst fr cvered rutine exams. Persnalized Preventin Plan Services (Annual Wellness Visit) Available t members in the first 12 mnths that they have Medicare Part B r 12 mnths after the member has the ne-time Initial Preventative Physical Exam (Welcme t Medicare Physical Exam). In-Netwrk $0 cpay fr Medicare-cvered services. Out-f-Netwrk 30% f the cst fr Medicarecvered services. Other Services Dialysis (kidney) Cvered services include: In-Netwrk 20% f the cst fr Medicare-

47 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 44 Outpatient dialysis treatments (including dialysis treatments when temprarily ut f the service area, as explained in Chapter 3)) Inpatient dialysis treatments (if yu are admitted t a hspital fr special care) Self-dialysis training (includes training fr yu and anyne helping yu with yur hme dialysis treatments) Hme dialysis equipment and supplies Certain hme supprt services (such as, when necessary, visits by trained dialysis wrkers t check n yur hme dialysis, t help in emergencies, and check yur dialysis equipment and water supply) cvered renal dialysis. Out-f-Netwrk 30% f the cst fr Medicarecvered renal dialysis. Medicare Part B prescriptin drugs These drugs are cvered under Part B f Original Medicare. Members f ur plan receive cverage fr these drugs thrugh ur plan. Cvered drugs include: Drugs that usually aren t self-administered by the patient and are injected while yu are getting physician services Drugs yu take using durable medical equipment (such as nebulizers) that was authrized by the plan Cltting factrs yu give yurself by injectin if yu have hemphilia Immunsuppressive Drugs, if yu were enrlled in Medicare Part A at the time f the rgan transplant Injectable steprsis drugs, if yu are hmebund, have a bne fracture that a dctr certifies was related t pst-menpausal steprsis, and cannt self-administer the drug Antigens Certain ral anti-cancer drugs and anti-nausea drugs Certain drugs fr hme dialysis, including heparin, the antidte fr heparin when medically necessary, tpical anesthetics, and erythrpisis-stimulating agents (such as EpgenÒ, PrcritÒ, Epetin Alfa, AranespÒ, r Darbepetin Alfa) Intravenus Immune Glbulin fr the hme treatment f primary immune deficiency diseases Chapter 5 explains the Part D prescriptin drug benefit, In-Netwrk 20% f the cst fr Part B-cvered chemtherapy drugs and ther Part B-cvered drugs. Out-f-Netwrk 30% f the cst fr Part B-cvered chemtherapy drugs and ther Part B-cvered drugs.

48 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 45 including rules yu must fllw t have prescriptins cvered. What yu pay fr yur Part D prescriptin drugs thrugh ur plan is listed in Chapter 6. Additinal Benefits Dental services In general, preventive dental benefits (such as cleaning) nt cvered. In-Netwrk $35 cpay fr Medicare-cvered dental benefits. Out-f-Netwrk 30% f the cst fr Medicarecvered dental benefits. Hearing services In general, rutine hearing exams and hearing aids nt cvered. In-Netwrk $35 cpay fr Medicare-cvered diagnstic hearing exams Out-f-Netwrk 30% f the cst fr Medicarecvered diagnstic hearing exams. Health and wellness educatin prgrams These are prgrams fcused n clinical health cnditins such as high bld pressure, chlesterl, asthma, and special diets. Prgrams designed t enrich the health and lifestyles f members include weight management, smking cessatin, fitness, and stress management. In-Netwrk The plan cvers the fllwing health/wellness educatin benefits: - Written health educatin materials, including Newsletters - Free basic membership in SilverSneakers fitness centers. - Nursing Htline fr members suffering with depressin. $0 cpay fr each Medicarecvered smking cessatin cunseling sessin. Out-f-Netwrk 30% f the cst fr Medicarecvered smking cessatin

49 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 46 cunseling sessin. Yu pay a $250 deductible. After yur deductible is met, yu pay 50% fr gym visits t any fitness center nt affiliated with SilverSneakers. There is a limit f $10 in allwed charges per visit. The plan maximum fr ut-fnetwrk gym visits is $750 (this includes the amunt yu pay and the amunt the plan pays). Yur gym must bill us directly fr these services. SECTION 3 What types f benefits are nt cvered by the plan? Sectin 3.1 Types f benefits we d nt cver (exclusins) This sectin tells yu what kind f benefits are excluded. Excluded means that the plan desn t cver these benefits. The list belw describes sme services and items that aren t cvered under any cnditins and sme that are excluded nly under specific cnditins. If yu get benefits that are excluded, yu must pay fr them yurself. We wn t pay fr the medical benefits listed in this sectin (r elsewhere in this bklet), and neither will Original Medicare. The nly exceptin: If a benefit n the exclusin list is fund upn appeal t be a medical benefit that we shuld have paid fr r cvered because f yur specific situatin. (Fr infrmatin abut appealing a decisin we have made t nt cver a medical service, g t Chapter 9, Sectin 5.3 in this bklet.) In additin t any exclusins r limitatins described in the Benefits Chart, r anywhere else in this Evidence f Cverage, the fllwing items and services aren t cvered under Original Medicare r by ur plan: Services cnsidered nt reasnable and necessary, accrding t the standards f Original Medicare, unless these services are listed by ur plan as a cvered services. Experimental medical and surgical prcedures, equipment and medicatins, unless cvered by Original Medicare. Hwever, certain services may be cvered under a Medicare-apprved clinical research study. See Chapter 3, Sectin 5 fr mre infrmatin n clinical research studies. Surgical treatment fr mrbid besity, except when it is cnsidered medically necessary and cvered under Original Medicare. Private rm in a hspital, except when it is cnsidered medically necessary. Private duty nurses.

50 Chapter 4: Medical benefit chart (what is cvered and what yu pay) 47 Persnal items in yur rm at a hspital r a skilled nursing facility, such as a telephne r a televisin. Full-time nursing care in yur hme. Custdial care, unless it is prvided with cvered skilled nursing care and/r skilled rehabilitatin services. Custdial care, r nn-skilled care, is care that helps yu with activities f daily living, such as bathing r dressing. Hmemaker services include basic husehld assistance, including light husekeeping r light meal preparatin. Fees charged by yur immediate relatives r members f yur husehld. Meals delivered t yur hme. Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance), except when medically necessary. Csmetic surgery r prcedures, unless because f an accidental injury r t imprve a malfrmed part f the bdy. Hwever, all stages f recnstructin are cvered fr a breast after a mastectmy, as well as fr the unaffected breast t prduce a symmetrical appearance. Rutine dental care, such as cleanings, filings r dentures. Hwever, nn-rutine dental care received at a hspital may be cvered. Chirpractic care, ther than manual manipulatin f the spine cnsistent with Medicare cverage guidelines. Rutine ft care, except fr the limited cverage prvided accrding t Medicare guidelines. Orthpedic shes, unless the shes are part f a leg brace and are included in the cst f the brace r the shes are fr a persn with diabetic ft disease. Supprtive devices fr the feet, except fr rthpedic r therapeutic shes fr peple with diabetic ft disease. Hearing aids and rutine hearing examinatins. Eyeglasses, rutine eye examinatins, radial kerattmy, LASIK surgery, visin therapy and ther lw visin aids. Hwever, eyeglasses are cvered fr peple after cataract surgery. Outpatient prescriptin drugs including drugs fr treatment f sexual dysfunctin, including erectile dysfunctin, imptence, and anrgasmy r hyprgasmy. Reversal f sterilizatin prcedures, sex change peratins, and nn-prescriptin cntraceptive supplies. Acupuncture. Naturpath services (uses natural r alternative treatments). Services prvided t veterans in Veterans Affairs (VA) facilities. Hwever, when emergency services are received at VA hspital and the VA cst-sharing is mre than the cst-sharing under ur plan. We will reimburse veterans fr the difference. Members are still respnsible fr ur cst-sharing amunts. Any services listed abve that aren t cvered will remain nt cvered even if received at an emergency facility.

51 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 48 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs SECTION 1 Intrductin 50 Sectin 1.1 This chapter describes yur cverage fr Part D drugs 50 Sectin 1.2 Basic rules fr the plan s Part D drug cverage 50 SECTION 2 Yur prescriptins shuld be written by a netwrk prvider 51 Sectin 2.1 In mst cases, yur prescriptin must be frm a netwrk prvider 51 SECTION 3 Fill yur prescriptin at a netwrk pharmacy r thrugh the plan s mail-rder service 51 Sectin 3.1 T have yur prescriptin cvered, use a netwrk pharmacy 51 Sectin 3.2 Finding netwrk pharmacies 51 Sectin 3.3 Using the plan s mail-rder services 52 Sectin 3.4 Hw can yu get a lng-term supply f drugs? 52 Sectin 3.5 When can yu use a pharmacy that is nt in the plan s netwrk? 52 SECTION 4 Yur drugs need t be n the plan s Drug List 53 Sectin 4.1 The Drug List tells which Part D drugs are cvered 53 Sectin 4.2 There are 4 cst-sharing tiers fr drugs n the Drug List 54 Sectin 4.3 Hw can yu find ut if a specific drug is n the Drug List? 54 SECTION 5 There are restrictins n cverage fr sme drugs 54 Sectin 5.1 Why d sme drugs have restrictins? 54 Sectin 5.2 What kinds f restrictins? 54 Sectin 5.3 D any f these restrictins apply t yur drugs? 55 SECTION 6 What if ne f yur drugs is nt cvered in the way yu d like it t be cvered? 55 Sectin 6.1 Sectin 6.2 There are things yu can d if yur drug is nt cvered in the way yu d like it t be cvered 55 What can yu d if yur drug is nt n the Drug List r if the drug is restricted in sme way? 56 Sectin 6.3 What can yu d if yur drug is in a cst-sharing tier yu think is t high? 58 SECTION 7 What if yur cverage changes fr ne f yur drugs? 58

52 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 49 Sectin 7.1 The Drug List can change during the year 58 Sectin 7.2 What happens if cverage changes fr a drug yu are taking? 58 SECTION 8 What types f drugs are nt cvered by the plan? 59 Sectin 8.1 Types f drugs we d nt cver 59 SECTION 9 Shw yur plan membership card when yu fill a prescriptin 60 Sectin 9.1 Shw yur membership card 60 Sectin 9.2 What if yu dn t have yur membership card with yu? 60 SECTION 10 Part D drug cverage in special situatins 61 Sectin 10.1 What if yu re in a hspital r a skilled nursing facility fr a stay that is cvered by the plan? 61 Sectin 10.2 What if yu re a resident in a lng-term care facility? 61 Sectin 10.3 What if yu re als getting drug cverage frm an emplyer r retiree grup plan? 62 SECTION 11 Prgrams n drug safety and managing medicatins 62 Sectin 11.1 Prgrams t help members use drugs safely 62 Sectin 11.2 Prgrams t help members manage their medicatins 62

53 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 50? Did yu knw there are prgrams t help peple pay fr their drugs? There are prgrams t help peple with limited resurces pay fr their drugs. The Extra Help prgram helps peple with limited resurces pay fr their drugs. Fr mre infrmatin, see Chapter 2, Sectin 7. Are yu currently getting help t pay fr yur drugs? If yu are in a prgram that helps pay fr yur drugs, sme infrmatin in this Evidence f Cverage may nt apply t yu. We have included a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (LIS Rider), that tells yu abut yur drug cverage. If yu dn t have this insert, please call Member Services and ask fr the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (LIS Rider). Phne numbers fr Member Services are n the frnt cver. SECTION 1 Sectin 1.1 Intrductin This chapter describes yur cverage fr Part D drugs This chapter explains rules fr using yur cverage fr Part D drugs. The next chapter tells what yu pay fr Part D drugs (Chapter 6, What yu pay fr yur Part D prescriptin drugs). In additin t yur cverage fr Part D drugs, Medi-Pak Advantage MA-PD Optin 1 (PFFS) als cvers sme drugs under the plan s medical benefits: The plan cvers drugs yu are given during cvered stays in the hspital r in a skilled nursing facility. Chapter 4 (Medical benefits chart, what is cvered and what yu pay), tells abut the benefits and csts fr drugs during a cvered hspital r skilled nursing facility stay. Medicare Part B als prvides benefits fr sme drugs. Part B drugs include certain chemtherapy drugs, certain drug injectins yu are given during an ffice visit, and drugs yu are given at a dialysis facility. Chapter 4 (Medical benefits chart, what is cvered and what yu pay) tells abut yur benefits and csts fr Part B drugs. The tw examples f drugs described abve are cvered by the plan s medical benefits. The rest f yur prescriptin drugs are cvered under the plan s Part D benefits. This chapter explains rules fr using yur cverage fr Part D drugs. The next chapter tells what yu pay fr Part D drugs (Chapter 6, What yu pay fr yur Part D prescriptin drugs). Sectin 1.2 Basic rules fr the plan s Part D drug cverage The plan will generally cver yur drugs as lng as yu fllw these basic rules: Yu must use a netwrk pharmacy t fill yur prescriptin. (See Sectin 3, Fill yur prescriptins at a netwrk pharmacy.)

54 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 51 Yur drug must be n the plan s List f Cvered Drugs (Frmulary) (we call it the Drug List fr shrt). (See Sectin 4, Yur drugs need t be n the plan s drug list.) Yur drug must be cnsidered medically necessary, meaning reasnable and necessary fr treatment f yur illness r injury. It als needs t be an accepted treatment fr yur medical cnditin SECTION 2 Yur prescriptins shuld be written by a netwrk prvider This sectin has been mitted because it des nt apply t ur plan SECTION 3 Fill yur prescriptin at a netwrk pharmacy r thrugh the plan s mail-rder service Sectin 3.1 T have yur prescriptin cvered, use a netwrk pharmacy In mst cases, yur prescriptins are cvered nly if they are filled at the plan s netwrk pharmacies. (See Sectin 3.5 fr infrmatin abut when we wuld cver prescriptins filled at ut-f-netwrk pharmacies.) A netwrk pharmacy is a pharmacy that has a cntract with the plan t prvide yur cvered prescriptin drugs. The term cvered drugs means all f the Part D prescriptin drugs that are cvered by the plan. Sectin 3.2 Finding netwrk pharmacies Hw d yu find a netwrk pharmacy in yur area? Yu can lk in yur Pharmacy Directry, visit ur website r call Member Services (phne numbers are n the cver). Chse whatever is easiest fr yu. Yu may g t any f ur netwrk pharmacies. If yu switch frm ne netwrk pharmacy t anther, and yu need a refill f a drug yu have been taking, yu can ask t either have a new prescriptin written by a dctr r t have yur prescriptin transferred t yur new netwrk pharmacy. What if the pharmacy yu have been using leaves the netwrk? If the pharmacy yu have been using leaves the plan s netwrk, yu will have t find a new pharmacy that is in the netwrk. T find anther netwrk pharmacy in yur area, yu can get help frm Member Services (phne numbers are n the cver) r use the Pharmacy Directry. What if yu need a specialized pharmacy? Smetimes prescriptins must be filled at a specialized pharmacy. Specialty pharmacies include: Pharmacies that supply drugs fr hme infusin therapy. Pharmacies that supply drugs fr residents f a lng-term-care facility. Usually, a lng-term care facility (such as a nursing hme) has its wn pharmacy. Residents may get prescriptin drugs thrugh the facility s pharmacy as lng as it is part f ur netwrk. If yur lng-term care pharmacy is nt in ur netwrk, please cntact Member Services.

55 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 52 Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Prgram (nt available in Puert Ric). Except in emergencies, nly Native Americans r Alaska Natives have access t these pharmacies in ur netwrk. Pharmacies that dispense certain drugs that are restricted by the FDA t certain lcatins, require extrardinary handling, prvider crdinatin, r educatin n its use. (Nte: This scenari shuld happen rarely.) T lcate a specialized pharmacy, lk in yur Pharmacy Directry r call Member Services. Sectin 3.3 Using the plan s mail-rder services Our plan s mail-rder service requires yu t rder at least a 30-day supply f the drug and n mre than a 90-day supply. T get rder frms and infrmatin abut filling yur prescriptins by mail call Member Service. If yu use a mail rder pharmacy nt in the plan s netwrk, yur prescriptin will nt be cvered. Usually a mail-rder pharmacy rder will get t yu in n mre than 14 days. Hwever, smetimes yur mailrder may be delayed. If yur mail rder shipment is delayed and yu need yur prescriptin immediately, we will wrk with yu t ensure that yu receive yur prescriptin. We can either expedite yur rder, r arrange t have yur prescriptin filled lcally at a retail netwrk pharmacy. If yur medicatin must be taken immediately, ask yur physician t issue tw prescriptins, ne fr a shrt supply t be taken t yur lcal retail netwrk pharmacy, and a secnd fr an extended supply t be mailed t us. Cntact Member Service if yu need assistance. Sectin 3.4 Hw can yu get a lng-term supply f drugs? When yu get a lng-term supply f drugs, yur cst sharing may be lwer. The plan ffers tw ways t get a lng-term supply f mail-rder drugs n ur plan s Drug List. (Mail-rder drugs are drugs that yu take n a regular basis, fr a chrnic r lng-term medical cnditin.) 1. Sme retail pharmacies in ur netwrk allw yu t get a lng-term supply f mail-rder drugs. Sme f these retail pharmacies may agree t accept mail-rder cst-sharing amunt fr a lng-term supply f mail-rder drugs. Yur Pharmacy Directry tells yu which pharmacies in ur netwrk can give yu a lng-term supply f mail-rder drugs. Yu can als call Member Services fr mre infrmatin. 2. Fr certain kinds f drugs, yu can use the plan s netwrk mail-rder services. These drugs are marked as mail-rder drugs n ur plan s Drug List. Our plan s mail-rder service requires yu t rder at least a 30-day supply f the drug and n mre than a 90-day supply. See Sectin 3.3 fr mre infrmatin abut using ur mail-rder services. Sectin 3.5 When can yu use a pharmacy that is nt in the plan s netwrk? Yur prescriptin might be cvered in certain situatins We have netwrk pharmacies utside f ur service area where yu can get yur prescriptins filled as a member f ur plan. Generally, we cver drugs filled at an ut-f-netwrk pharmacy nly when yu are nt

56 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 53 able t use a netwrk pharmacy. Here are the circumstances when we wuld cver prescriptins filled at an utf-netwrk pharmacy: If the prescriptins are related t care fr a medical emergency r urgently needed care. If yu are traveling within the US, but utside f the Plans service area, and yu becme ill, lse, r run ut f yur prescriptin drugs, and if yu fllw all ther cverage rules identified within this dcument and a netwrk pharmacy is nt available. If yu are unable t get a cvered drug in a timely manner within ur service area because there are n netwrk pharmacies within a reasnable driving distance that prvides 24-hur service. If yu trying t fill a cvered prescriptin drug that is nt regularly stcked at an eligible netwrk retail r mail rder pharmacy (these drugs include rphan drugs r ther specialty pharmaceuticals). In these situatins, please check first with Member Services t see if there is a netwrk pharmacy nearby. Hw d yu ask fr reimbursement frm the plan? If yu must use an ut-f-netwrk pharmacy, yu will generally have t pay the full cst (rather than paying yur nrmal share f the cst) when yu fill yur prescriptin. Yu can ask us t reimburse yu fr ur share f the cst. (Chapter 7, Sectin 2.1 explains hw t ask the plan t pay yu back). SECTION 4 Yur drugs need t be n the plan s Drug List Sectin 4.1 The Drug List tells which Part D drugs are cvered The plan has a List f Cvered Drugs (Frmulary). In this Evidence f Cverage, we call it the Drug List fr shrt. The drugs n this list are selected by the plan with the help f a team f dctrs and pharmacists. The list must meet requirements set by Medicare. Medicare has apprved the plan s Drug List. The drugs n the Drug List are nly thse cvered under Medicare Part D (earlier in this chapter, Sectin 1.1 explains abut Part D drugs). We will generally cver a drug n the plan s Drug List as lng as yu fllw the ther cverage rules explained in this chapter and the drug is medically necessary, meaning reasnable and necessary fr treatment f yur illness r injury. It als needs t be prescribed fr an accepted treatment fr yur medical cnditin. The Drug List includes bth brand-name and generic drugs A generic drug is a prescriptin drug that has the same active ingredients as the brand-name drug. It wrks just as well as the brand-name drug, but it csts less. There are generic drug substitutes available fr many brandname drugs. What is nt n the Drug list? The plan des nt cver all prescriptin drugs.

57 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 54 In sme cases, the law des nt allw any Medicare plan t cver certain types f drugs (fr mre abut this, see Sectin 8.1 in this chapter). In ther cases, we have decided nt t include a particular drug n ur Drug List. Sectin 4.2 There are fur cst-sharing tiers fr drugs n the Drug List Every drug n the plan s Drug List is in ne f 4 cst-sharing tiers. In general, the higher the cst-sharing tier, the higher yur cst fr the drug: Cst-Sharing Tier 1 includes generic drugs, which is the lwest tier. Cst-Sharing Tier 2 includes Preferred Brand, which is the next lwest tier. Cst-Sharing Tier 3 includes Nn-Preferred Brand, which is the next t the highest tier. Cst-Sharing Tier 4 includes Specialty drugs, highest tier. T find ut which cst-sharing tier yur drug is in, lk it up in the plan s Drug List. The amunt yu pay fr drugs in each cst-sharing tier is shwn in Chapter 6 (What yu pay fr yur Part D prescriptin drugs). Sectin 4.3 Hw can yu find ut if a specific drug is n the Drug List? Yu have three ways t find ut: 1. Check the mst recent Drug List we sent yu in the mail. 2. Visit the plan s website ( The Drug List n the website is always the mst current. 3. Call Member Services t find ut if a particular drug is n the plan s Drug List r t ask fr a cpy f the list. Phne numbers fr Member Services are n the frnt cver. SECTION 5 There are restrictins n cverage fr sme drugs Sectin 5.1 Why d sme drugs have restrictins? Fr certain prescriptin drugs, special rules restrict hw and when the plan cvers them. A team f dctrs and pharmacists develped these rules t help ur members use drugs in the mst effective ways. These special rules als help cntrl verall drug csts, which keeps yur drug cverage mre affrdable. In general, ur rules encurage yu get a drug that wrks fr yur medical cnditin and is safe. Whenever a safe, lwer-cst drug will wrk medically just as well as a higher-cst drug, the plan s rules are designed t encurage yu and yur dctr r ther prescriber t use that lwer-cst ptin. We als need t cmply with Medicare s rules and regulatins fr drug cverage and cst sharing. Sectin 5.2 What kinds f restrictins? Our plan uses different types f restrictins t help ur members use drugs in the mst effective ways. The sectins belw tell yu mre abut the types f restrictins we use fr certain drugs.

58 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 55 Restricting brand name drugs when a generic versin is available A generic drug wrks the same as a brand name drug, but usually csts less. When a generic versin f a brand name drug is available, ur netwrk pharmacies will prvide yu the generic versin. We usually will nt cver the brand name drug when a generic versin is available. Hwever, if yur dctr has tld us the medical reasn that the generic drug will nt wrk fr yu, then we will cver the brand name drug. (Yur share f the cst may be greater fr the brand name drug than fr the generic drug.) Getting plan apprval in advance Fr certain drugs, yu r yur dctr need t get apprval frm the plan befre we will agree t cver the drug fr yu. This is called prir authrizatin. Smetimes plan apprval is required s we can be sure that yur drug is cvered by Medicare rules. Smetimes the requirement fr getting apprval in advance helps guide apprpriate use f certain drugs. If yu d nt get this apprval, yur drug might nt be cvered by the plan. Trying a different drug first This requirement encurages yu t try safer r mre effective drugs befre the plan cvers anther drug. Fr example, if Drug A and Drug B treat the same medical cnditin, the plan may require yu t try Drug A first. If Drug A des nt wrk fr yu, the plan will then cver Drug B. This requirement t try a different drug first is called Step Therapy. Quantity limits Fr certain drugs, we limit the amunt f the drug that yu can have. Fr example, the plan might limit hw many refills yu can get, r hw much f a drug yu can get each time yu fill yur prescriptin. Fr example, if it is nrmally cnsidered safe t take nly ne pill per day fr a certain drug, we may limit cverage fr yur prescriptin t n mre than ne pill per day. Sectin 5.3 D any f these restrictins apply t yur drugs? The plan s Drug List includes infrmatin abut the restrictins described abve. T find ut if any f these restrictins apply t a drug yu take r want t take, check the Drug List. Fr the mst up-t-date infrmatin, call Member Services (phne numbers are n the frnt cver) r check ur website ( SECTION 6 What if ne f yur drugs is nt cvered in the way yu d like it t be cvered? Sectin 6.1 There are things yu can d if yur drug is nt cvered in the way yu d like it t be cvered Suppse there is a prescriptin drug yu are currently taking, r ne that yu and yur dctr think yu shuld be taking. We hpe that yur drug cverage will wrk well fr yu, but it s pssible that yu might have a prblem. Fr example:

59 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 56 What if the drug yu want t take is nt cvered by the plan? Fr example, the drug might nt be cvered at all. Or maybe a generic versin f the drug is cvered but the brand name versin yu want t take is nt cvered. What if the drug is cvered, but there are extra rules r restrictins n cverage fr that drug? As explained in Sectin 5, sme f the drugs cvered by the plan have extra rules t restrict their use. Fr example, yu might be required t try a different drug first, t see if it will wrk, befre the drug yu want t take will be cvered fr yu. Or there might be limits n what amunt f the drug (number f pills, etc.) is cvered during a particular time perid. What if the drug is cvered, but it is in a cst-sharing tier that makes yur cst sharing mre expensive than yu think it shuld be? The plan puts each cvered drug int ne f 4 different cstsharing tiers. Hw much yu pay fr yur prescriptin depends in part n which cst-sharing tier yur drug is in. There are things yu can d if yur drug is nt cvered in the way that yu d like it t be cvered. Yur ptins depend n what type f prblem yu have: If yur drug is nt n the Drug List r if yur drug is restricted, g t Sectin 6.2 t learn what yu can d. If yur drug is in a cst-sharing tier that makes yur cst mre expensive than yu think it shuld be, g t Sectin 6.3 t learn what yu can d. Sectin 6.2 What can yu d if yur drug is nt n the Drug List r if the drug is restricted in sme way? If yur drug is nt n the Drug List r is restricted, here are things yu can d: Yu may be able t get a temprary supply f the drug (nly members in certain situatins can get a temprary supply). This will give yu and yur dctr time t change t anther drug r t file an exceptin. Yu can change t anther drug. Yu can request an exceptin and ask the plan t cver the drug r remve restrictins frm the drug. Yu may be able t get a temprary supply Under certain circumstances, the plan can ffer a temprary supply f a drug t yu when yur drug is nt n the Drug List r when it is restricted in sme way. Ding this gives yu time t talk with yur dctr abut the change in cverage and figure ut what t d. T be eligible fr a temprary supply, yu must meet the tw requirements given belw: 1. The change t yur drug cverage must be ne f the fllwing types f changes: The drug yu have been taking is n lnger n the plan s Drug List. -- r -- the drug yu have been taking is nw restricted in sme way (Sectin 5 in this chapter tells abut restrictins).

60 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs Yu must be in ne f the situatins described belw: Fr thse members wh were in the plan last year and aren t in a lng-term care facility: We will cver a temprary supply f yur drug ne time nly during the first 90 day f the calendar year. This temprary supply will be fr a maximum f a 30-day supply, r less if yur prescriptin is written fr fewer days. The prescriptin must be filled at a netwrk pharmacy. Fr thse members wh are new t the plan and aren t in a lng-term care facility: We will cver a temprary supply f yur drug ne time nly during the first 90 days f yur membership in the plan. This temprary supply will be fr a maximum f a 30-day supply, r less if yur prescriptin is written fr fewer days. The prescriptin must be filled at a netwrk pharmacy. Fr thse wh are a new member and a resident in a lng-term care facility: We will cver a temprary supply f yur drug during the first 90 days f yur membership in the plan. The first supply will be fr a maximum f a 31-day supply, r less if yur prescriptin is written fr fewer days. If needed, we will cver additinal refills during yur first 90 days in the plan. Fr thse wh have been a member f the plan fr mre than 90 days and are a resident f a lngterm care facility and need a supply right away: We will cver ne a 31-day supply, r less if yur prescriptin is written fr fewer days. This is in additin t the abve lng-term care transitin supply. Fr current members wh are being admitted t r discharged frm a lng-term care facility: We will cver ne 31-day supply, r less if yur prescriptin is written fr fewer days upn admissin r discharge. T ask fr a temprary supply, call Member Services (phne numbers are n the frnt cver). During the time when yu are getting a temprary supply f a drug, yu shuld talk with yur dctr t decide what t d when yur temprary supply runs ut. Perhaps there is a different drug cvered by the plan that might wrk just as well fr yu. Or yu and yur dctr can ask the plan t make an exceptin fr yu and cver the drug in the way yu wuld like it t be cvered. The sectins belw tell yu mre abut these ptins. Yu can change t anther drug Start by talking with yur dctr. Perhaps there is a different drug cvered by the plan that might wrk just as well fr yu. Yu can call Member Services t ask fr a list f cvered drugs that treat the same medical cnditin. This list can help yur dctr t find a cvered drug that might wrk fr yu. Yu can file an exceptin Yu and yur dctr r ther prescriber can ask the plan t make an exceptin fr yu and cver the drug in the way yu wuld like it t be cvered. If yur dctr r ther prescriber says that yu have medical reasns that justify asking us fr an exceptin, yur dctr r ther prescriber can help yu request an exceptin t the rule. Fr example, yu can ask the plan t cver a drug even thugh it is nt n the plan s Drug List. Or yu can ask the plan t make an exceptin and cver the drug withut restrictins. If yu are a current member and a drug yu are taking will be remved frm the frmulary r restricted in sme way fr next year, we will allw yu t request a frmulary exceptin in advance fr next year. We will tell yu abut any change in the cverage fr yur drug fr the fllwing year. Yu can then ask us t make an

61 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 58 exceptin and cver the drug in the way yu wuld like it t be cvered fr the fllwing year. We will give yu an answer t yur request fr an exceptin befre the change takes effect. If yu and yur dctr r ther prescriber want t ask fr an exceptin, Chapter 9, Sectin 6.2 tells what t d. It explains the prcedures and deadlines that have been set by Medicare t make sure yur request is handled prmptly and fairly. Sectin 6.3 What can yu d if yur drug is in a cst-sharing tier yu think is t high? If yur drug is a cst-sharing tier yu think is t high, here are things yu can d: Yu can change t anther drug Start by talking with yur dctr. Perhaps there is a different drug in a lwer cst-sharing tier that might wrk just as well fr yu. Yu can call Member Services t ask fr a list f cvered drugs that treat the same medical cnditin. This list can help yur dctr t find a cvered drug that might wrk fr yu. Yu can file an exceptin Yu and yur dctr can ask the plan t make an exceptin in the cst-sharing tier fr the drug s that yu pay less fr the drug. If yur dctr r ther prvider says that yu have medical reasns that justify asking us fr an exceptin, yur dctr can help yu request an exceptin t the rule. If yu and yur dctr want t ask fr an exceptin, Chapter 9, Sectin 6.2 tells what t d. It explains the prcedures and deadlines that have been set by Medicare t make sure yur request is handled prmptly and fairly. SECTION 7 What if yur cverage changes fr ne f yur drugs? Sectin 7.1 The Drug List can change during the year Mst f the changes in drug cverage happen at the beginning f each year (January 1). Hwever, during the year, the plan might make many kinds f changes t the Drug List. Fr example, the plan might: Add r remve drugs frm the Drug List. New drugs becme available, including new generic drugs. Perhaps the gvernment has given apprval t a new use fr an existing drug. Smetimes, a drug gets recalled and we decide nt t cver it. Or we might remve a drug frm the list because it has been fund t be ineffective. Mve a drug t a higher r lwer cst-sharing tier. Add r remve a restrictin n cverage fr a drug (fr mre infrmatin abut restrictins t cverage, see Sectin 5 in this chapter). Replace a brand name drug with a generic drug. In almst all cases, we must get apprval frm Medicare fr any changes we make t the plan s Drug List. Sectin 7.2 What happens if cverage changes fr a drug yu are taking? Hw will yu find ut if yur drug s cverage has been changed?

62 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 59 If there is a change t cverage fr a drug yu are taking, the plan will send yu a ntice t tell yu. Nrmally, we will let yu knw at least 60 days ahead f time. Once in a while, a drug is suddenly recalled because it s been fund t be unsafe r fr ther reasns. If this happens, the plan will immediately remve the drug frm the Drug List. We will let yu knw f this change right away. Yur dctr will als knw abut this change, and can wrk with yu t find anther drug fr yur cnditin. D changes t yur drug cverage affect yu right away? If any f the fllwing types f changes affect a drug yu are taking, the change will nt affect yu until January 1 f the next year if yu stay in the plan: If we mve yur drug int a higher cst-sharing tier. If we put a new restrictin n yur use f the drug. If we remve yur drug frm the Drug List, but nt because f a sudden recall r because a new generic drug has replaced it. If any f these changes happens fr a drug yu are taking, then the change wn t affect yur use r what yu pay as yur share f the cst until January 1 f the next year. Until that date, yu prbably wn t see any increase in yur payments r any added restrictin t yur use f the drug. Hwever, n January 1 f the next year, the changes will affect yu. In sme cases, yu will be affected by the cverage change befre January 1: If a brand name drug yu are taking is replaced by a new generic drug, the plan must give yu at least 60 days ntice r give yu a 60-day refill f yur brand name drug at a netwrk pharmacy. During this 60-day perid, yu shuld be wrking with yur dctr t switch t the generic r t a different drug that we cver. Or yu and yur dctr r ther prescriber can ask the plan t make an exceptin and cntinue t cver the brand name drug fr yu. Fr infrmatin n hw t ask fr an exceptin, see Chapter 9 (What t d if yu have a prblem r cmplaint). Again, if a drug is suddenly recalled because it s been fund t be unsafe r fr ther reasns, the plan will immediately remve the drug frm the Drug List. We will let yu knw f this change right away. Yur dctr will als knw abut this change, and can wrk with yu t find anther drug fr yur cnditin. SECTION 8 What types f drugs are nt cvered by the plan? Sectin 8.1 Types f drugs we d nt cver This sectin tells yu what kinds f prescriptin drugs are excluded. This means Medicare des nt pay fr these drugs. If yu get drugs that are excluded, yu must pay fr them yurself. We wn t pay fr the drugs that are listed in this sectin (unless ur plan cvers certain excluded drugs). The nly exceptin: If the requested drug is fund upn appeal t be a drug that is nt excluded under Part D and we shuld have paid fr r cvered because f yur specific situatin. (Fr infrmatin abut appealing a decisin we have made t nt cver a drug, g t Chapter 9, Sectin 6.5 in this bklet.)

63 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 60 Here are three general rules abut drugs that Medicare drug plans will nt cver under Part D: Our plan s Part D drug cverage cannt cver a drug that wuld be cvered under Medicare Part A r Part B. Our plan cannt cver a drug purchased utside the United States and its territries. Our plan usually cannt cver ff-label use. Off-label use is any use f the drug ther than thse indicated n a drug s label as apprved by the Fd and Drug Administratin. Generally, cverage fr ff-label use is allwed nly when the use is supprted by certain reference bks. These reference bks are the American Hspital Frmulary Service Drug Infrmatin, the DRUGDEX Infrmatin System, and the USPDI r its successr. If the use is nt supprted by any f these reference bks, then ur plan cannt cver its ff-label use. Als, by law these categries f drugs are nt cvered by Medicare drug plans unless we ffer enhanced drug cverage, fr which yu may be charged additinal premium: Nn-prescriptin drugs (als called ver-the-cunter drugs) Drugs when used t prmte fertility Drugs when used fr the relief f cugh r cld symptms Drugs when used fr csmetic purpses r t prmte hair grwth Prescriptin vitamins and mineral prducts, except prenatal vitamins and fluride preparatins Drugs when used fr the treatment f sexual r erectile dysfunctin, such as Viagra, Cialis, Levitra, and Caverject Drugs when used fr treatment f anrexia, weight lss, r weight gain Outpatient drugs fr which the manufacturer seeks t require that assciated tests r mnitring services be purchased exclusively frm the manufacturer as a cnditin f sale Barbiturates and Benzdiazepines If yu receive Extra Help paying fr yur drugs, yur state Medicaid prgram may cver sme prescriptin drugs nt nrmally cvered in a Medicare drug plan. Please cntact yur state Medicaid prgram t determine what drug cverage may be available t yu. (Yu can find phne numbers and cntact infrmatin fr Medicaid in Chapter 2, Sectin 6.) SECTION 9 Shw yur plan membership card when yu fill a prescriptin Sectin 9.1 Shw yur membership card T fill yur prescriptin, shw yur plan membership card at the netwrk pharmacy yu chse. When yu shw yur plan membership card, the netwrk pharmacy will autmatically bill the plan fr ur share f yur cvered prescriptin drug cst. Yu will need t pay the pharmacy yur share f the cst when yu pick up yur prescriptin. Sectin 9.2 What if yu dn t have yur membership card with yu?

64 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 61 If yu dn t have yur plan membership card with yu when yu fill yur prescriptin, ask the pharmacy t call the plan t get the necessary infrmatin. If the pharmacy is nt able t get the necessary infrmatin, yu may have t pay the full cst f the prescriptin when yu pick it up. (Yu can then ask us t reimburse yu fr ur share. See Chapter 7, Sectin 2.1 fr infrmatin abut hw t ask the plan fr reimbursement.) SECTION 10 Sectin 10.1 Part D drug cverage in special situatins What if yu re in a hspital r a skilled nursing facility fr a stay that is cvered by the plan? If yu are admitted t a hspital r t a skilled nursing facility fr a stay cvered by the plan, we will generally cver the cst f yur prescriptin drugs during yur stay. Once yu leave the hspital r skilled nursing facility, the plan will cver yur drugs as lng as the drugs meet all f ur rules fr cverage. See the previus parts f this sectin that tell abut the rules fr getting drug cverage. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut drug cverage and what yu pay. Please Nte: When yu enter, live in, r leave a skilled nursing facility, yu are entitled t a special enrllment perid. During this time perid, yu can switch plans r change yur cverage at any time. (Chapter 10, Ending yur membership in the plan, tells yu can leave ur plan and jin a different Medicare plan.) Sectin 10.2 What if yu re a resident in a lng-term care facility? Usually, a lng-term care facility (such as a nursing hme) has its wn pharmacy, r a pharmacy that supplies drugs fr all f its residents. If yu are a resident f a lng-term care facility, yu may get yur prescriptin drugs thrugh the facility s pharmacy as lng as it is part f ur netwrk. Check yur Pharmacy Directry t find ut if yur lng-term care facility s pharmacy is part f ur netwrk. If it isn t, r if yu need mre infrmatin, please cntact Member Services. What if yu re a resident in a lng-term care facility and becme a new member f the plan? If yu need a drug that is nt n ur Drug List r is restricted in sme way, the plan will cver a temprary supply f yur drug during the first 90 days f yur membership. The first supply will be fr a maximum f a 31-day supply, r less if yur prescriptin is written fr fewer days. If needed, we will cver additinal refills during yur first 90 days in the plan. If yu have been a member f the plan fr mre than 90 days and need a drug that is nt n ur Drug List r if the plan has any restrictin n the drug s cverage, we will cver ne 31-day supply, r less if yur prescriptin is written fr fewer days. During the time when yu are getting a temprary supply f a drug, yu shuld talk with yur dctr r ther prescriber t decide what t d when yur temprary supply runs ut. Perhaps there is a different drug cvered by the plan that might wrk just as well fr yu. Or yu and yur dctr can ask the plan t make an exceptin fr yu and cver the drug in the way yu wuld like it t be cvered. If yu and yur dctr want t ask fr an exceptin, Chapter 9, Sectin 6.2 tells what t d.

65 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 62 Sectin 10.3 What if yu re als getting drug cverage frm an emplyer r retiree grup plan? D yu currently have ther prescriptin drug cverage thrugh yur (r yur spuse s) emplyer r retiree grup? If s, please cntact that grup s benefits administratr. He r she can help yu determine hw yur current prescriptin drug cverage will wrk with ur plan. In general, if yu are currently emplyed, the prescriptin drug cverage yu get frm us will be secndary t yur emplyer r retiree grup cverage. That means yur grup cverage wuld pay first. Special nte abut creditable cverage : Each year yur emplyer r retiree grup shuld send yu a ntice by Nvember 15 that tells if yur prescriptin drug cverage fr the next calendar year is creditable and the chices yu have fr drug cverage. If the cverage frm the grup plan is creditable, it means that it has drug cverage that pays, n average, at least as much as Medicare s standard drug cverage. Keep these ntices abut creditable cverage, because yu may need them later. If yu enrll in a Medicare plan that includes Part D drug cverage, yu may need these ntices t shw that yu have maintained creditable cverage. If yu didn t get a ntice abut creditable cverage frm yur emplyer r retiree grup plan, yu can get a cpy frm the emplyer r retiree grup s benefits administratr r the emplyer r unin. SECTION 11 Sectin 11.1 Prgrams n drug safety and managing medicatins Prgrams t help members use drugs safely We cnduct drug use reviews fr ur members t help make sure that they are getting safe and apprpriate care. These reviews are especially imprtant fr members wh have mre than ne prvider wh prescribes their drugs. We d a review each time yu fill a prescriptin. We als review ur recrds n a regular basis. During these reviews, we lk fr ptential prblems such as: Pssible medicatin errrs. Drugs that may nt be necessary because yu are taking anther drug t treat the same medical cnditin. Drugs that may nt be safe r apprpriate because f yur age r gender. Certain cmbinatins f drugs that culd harm yu if taken at the same time. Prescriptins written fr drugs that have ingredients yu are allergic t. Pssible errrs in the amunt (dsage) f a drug yu are taking. If we see a pssible prblem in yur use f medicatins, we will wrk with yur dctr t crrect the prblem. Sectin 11.2 Prgrams t help members manage their medicatins

66 Chapter 5: Using the plan s cverage fr yur Part D prescriptin drugs 63 We have prgrams that can help ur members with special situatins. Fr example, sme members have several cmplex medical cnditins r they may need t take many drugs at the same time, r they culd have very high drug csts. These prgrams are vluntary and free t members. A team f pharmacists and dctrs develped the prgrams fr us. The prgrams can help make sure that ur members are using the drugs that wrk best t treat their medical cnditins and help us identify pssible medicatin errrs. If we have a prgram that fits yur needs, we will autmatically enrll yu in the prgram and send yu infrmatin. If yu decide nt t participate, please ntify us and we will withdraw yur participatin in the prgram.

67 Chapter 6: What yu pay fr yur Part D prescriptin drugs 64 Chapter 6. What yu pay fr yur Part D prescriptin drugs SECTION 1 Intrductin 66 Sectin 1.1 Use this chapter tgether with ther materials that explain yur drug cverage 66 SECTION 2 What yu pay fr a drug depends n which drug payment stage yu are in when yu get the drug 67 Sectin 2.1 What are the 4 drug payment stages? 67 SECTION 3 We send yu reprts that explain payments fr yur drugs and which payment stage yu are in 68 Sectin 3.1 We send yu a mnthly reprt called the Explanatin f Benefits 68 Sectin 3.2 Help us keep ur infrmatin abut yur drug payments up t date 68 SECTION 4 During the Deductible Stage, yu pay the full cst f yur drugs 69 Sectin 4.1 Yu stay in the Deductible Stage until yu have paid $170 fr yur drugs 69 SECTION 5 During the Initial Cverage Stage, the plan pays its share f yur drug csts and yu pay yur share 69 Sectin 5.1 What yu pay fr a drug depends n the drug and where yu fill yur prescriptin 69 Sectin 5.2 Sectin 5.3 Sectin 5.4 A table that shws yur csts fr a ne-mnth 34-day supply f a drug 70 A table that shws yur csts fr a lng-term 90-day supply f a drug 71 Yu stay in the Initial Cverage Stage until yur ttal drug csts fr the year reach $2, SECTION 6 During the Cverage Gap Stage, yu receive a discunt n brand name drugs and pay nly 93% f the csts f generic drugs 72 Sectin 6.1 Yu stay in the Cverage Gap Stage until yur ut-f-pcket csts reach $4, Sectin 6.2 Hw Medicare calculates yur ut-f-pcket csts fr prescriptin drugs 72 SECTION 7 During the Catastrphic Cverage Stage, the plan pays mst f the cst fr yur drugs 74 Sectin 7.1 Once yu are in the Catastrphic Cverage Stage, yu will stay in this stage fr the rest f the year 74 SECTION 8 Additinal benefits infrmatin 74

68 Chapter 6: What yu pay fr yur Part D prescriptin drugs 65 Sectin 8.1 Our plan ffers additinal benefits 74 SECTION 9 What yu pay fr vaccinatins depends n hw and where yu get them 74 Sectin 9.1 Our plan has separate cverage fr the vaccine medicatin itself and fr the cst f giving yu the vaccinatin sht 74 Sectin 9.2 Yu may want t call us at Member Services befre yu get a vaccinatin 76 SECTION 10 D yu have t pay the Part D late enrllment penalty? 76 Sectin 10.1 What is the Part D late enrllment penalty? 76 Sectin 10.2 Hw much is the Part D late enrllment penalty? 76 Sectin 10.3 In sme situatins, yu can enrll late and nt have t pay the penalty 77 Sectin 10.4 What can yu d if yu disagree abut yur late enrllment penalty? 77

69 Chapter 6: What yu pay fr yur Part D prescriptin drugs 66? Did yu knw there are prgrams t help peple pay fr their drugs? The Extra Help prgram helps peple with limited resurces pay fr their drugs. Fr mre infrmatin, see Chapter 2, Sectin 7. Are yu currently getting help t pay fr yur drugs? If yu are in a prgram that helps pay fr yur drugs, sme infrmatin in this Evidence f Cverage may nt apply t yu. We have included a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (LIS Rider), that tells yu abut yur drug cverage. If yu dn t have this insert, please call Member Services and ask fr the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (LIS Rider). Phne numbers fr Member Services are n the frnt cver. SECTION 1 Intrductin Sectin 1.1 Use this chapter tgether with ther materials that explain yur drug cverage This chapter fcuses n what yu pay fr yur Part D prescriptin drugs. T keep things simple, we use drug in this chapter t mean a Part D prescriptin drug. As explained in Chapter 5, sme drugs are cvered under Original Medicare r are excluded by law. T understand the payment infrmatin we give yu in this chapter, yu need t knw the basics f what drugs are cvered, where t fill yur prescriptins, and what rules t fllw when yu get yur cvered drugs. Here are materials that explain these basics: The plan s List f Cvered Drugs (Frmulary). T keep things simple, we call this the Drug List. This Drug List tells which drugs are cvered fr yu. It als tells which f the 4 cst-sharing tiers the drug is in and whether there are any restrictins n yur cverage fr the drug. If yu need a cpy f the Drug List, call Member Services (phne numbers are n the cver f this bklet). Yu can als find the Drug List n ur website at The Drug List n the website is always the mst current. Chapter 5 f this bklet. Chapter 5 gives the details abut yur prescriptin drug cverage, including rules yu need t fllw when yu get yur cvered drugs. Chapter 5 als tells which types f prescriptin drugs are nt cvered by ur plan.

70 Chapter 6: What yu pay fr yur Part D prescriptin drugs 67 The plan s Pharmacy Directry. In mst situatins yu must use a netwrk pharmacy t get yur cvered drugs (see Chapter 5 fr the details). The Pharmacy Directry has a list f pharmacies in the plan s netwrk and it tells hw yu can use the plan s mail-rder service t get certain types f drugs It als explains hw yu can get a lng-term supply f a drug (such as filling a prescriptin fr a three mnth s supply). SECTION 2 What yu pay fr a drug depends n which drug payment stage yu are in when yu get the drug Sectin 2.1 What are the fur drug payment stages? As shwn in the table belw, there are fur drug payment stages fr yur prescriptin drug cverage. Hw much yu pay fr a drug depends n which f these stages yu are in at the time yu get a prescriptin filled r refilled. Keep in mind yu are always respnsible fr the plan s mnthly premium regardless f the drug payment stage. Stage 1 Stage 2 Stage 3 Stage 4 Yearly Deductible Stage Initial Cverage Stage Cverage Gap Stage Catastrphic Cverage Stage Yu begin in this payment stage when yu fill yur first prescriptin f the year. During this stage yu pay the full cst f yur drugs. Yu stay in this stage until yu have paid $170 fr yur drugs ($170 is the amunt f yur deductible). (Details are in Sectin 4 f this chapter.) The plan pays its share f the cst f yur drugs and yu pay yur share f the cst. Yu stay in this stage until yur payments fr the year plus the plan s payments ttal $2,840. (Details are in Sectin 5 f this chapter.) Yu receive a discunt n brand name drugs and yu pay nly 93% f the csts f generic drugs. Yu stay in this stage until yur ut-fpcket csts reach a ttal f $$4,550. This amunt and rules fr cunting csts tward this amunt have been set by Medicare. (Details are in Sectin 6 f this chapter.) Once yu have paid enugh fr yur drugs t mve n t this last payment stage, the plan will pay mst f the cst f yur drugs fr the rest f the year. (Details are in Sectin 7 f this chapter.) As shwn in this summary f the 4 payment stages, whether yu mve n t the next payment stage depends n hw much yu and/r the plan spends fr yur drugs while yu are in each stage.

71 Chapter 6: What yu pay fr yur Part D prescriptin drugs 68 SECTION 3 We send yu reprts that explain payments fr yur drugs and which payment stage yu are in Sectin 3.1 We send yu a mnthly reprt called the Explanatin f Benefits Our plan keeps track f the csts f yur prescriptin drugs and the payments yu have made when yu get yur prescriptins filled r refilled at the pharmacy. This way, we can tell yu when yu have mved frm ne drug payment stage t the next. In particular, there are tw types f csts we keep track f: We keep track f hw much yu have paid. This is called yur ut-f-pcket cst. We keep track f yur ttal drug csts. This is the amunt yu pay ut-f-pcket r thers pay n yur behalf plus the amunt paid by the plan. Our plan will prepare a written reprt called the Explanatin f Benefits (it is smetimes called the EOB ) when yu have had ne r mre prescriptins filled. It includes: Infrmatin fr that mnth. This reprt gives the payment details abut the prescriptins yu have filled during the previus mnth. It shws the ttal drug csts, what the plan paid, and what yu and thers n yur behalf paid. Ttals fr the year since January 1. This is called year-t-date infrmatin. It shws yu the ttal drug csts and ttal payments fr yur drugs since the year began. Sectin 3.2 Help us keep ur infrmatin abut yur drug payments up t date T keep track f yur drug csts and the payments yu make fr drugs, we use recrds we get frm pharmacies. Here is hw yu can help us keep yur infrmatin crrect and up t date: Shw yur membership card when yu get a prescriptin filled. T make sure we knw abut the prescriptins yu are filling and what yu are paying, shw yur plan membership card every time yu get a prescriptin filled. Make sure we have the infrmatin we need. There are times yu may pay fr prescriptin drugs when we will nt autmatically get the infrmatin we need. T help us keep track f yur ut-fpcket csts, yu may give us cpies f receipts fr drugs that yu have purchased. (If yu are billed fr a cvered drug, yu can ask ur plan t pay ur share f the cst. Fr instructins n hw t d this, g t Chapter 7, Sectin 2 f this bklet.) Here are sme types f situatins when yu may want t give us cpies f yur drug receipts t be sure we have a cmplete recrd f what yu have spent fr yur drugs: When yu purchase a cvered drug at a netwrk pharmacy at a special price r using a discunt card that is nt part f ur plan s benefit. When yu made a cpayment fr drugs that are prvided under a drug manufacturer patient assistance prgram. Any time yu have purchased cvered drugs at ut-f-netwrk pharmacies r ther times yu have paid the full price fr a cvered drug under special circumstances.

72 Chapter 6: What yu pay fr yur Part D prescriptin drugs 69 Send us infrmatin abut the payments thers have made fr yu. Payments made by certain ther individuals and rganizatins als cunt tward yur ut-f-pcket csts and help qualify yu fr catastrphic cverage. Fr example, payments made by a State Pharmaceutical Assistance Prgram, an AIDS drug assistance prgram, the Indian Health Service, and mst charities cunt tward yur ut-fpcket csts. Yu shuld keep a recrd f these payments and send them t us s we can track yur csts. Check the written reprt we send yu. When yu receive an Explanatin f Benefits in the mail, please lk it ver t be sure the infrmatin is cmplete and crrect. If yu think smething is missing frm the reprt, r yu have any questins, please call us at Member Services (phne numbers are n the cver f this bklet). Be sure t keep these reprts. They are an imprtant recrd f yur drug expenses. SECTION 4 During the Deductible Stage, yu pay the full cst f yur drugs Sectin 4.1 Yu stay in the Deductible Stage until yu have paid $170 fr yur drugs The Deductible Stage is the first payment stage fr yur drug cverage. This stage begins when yu fill yur first prescriptin in the year. When yu are in this payment stage, yu must pay the full cst f yur drugs until yu reach the plan s deductible amunt, which is $170 fr Yur full cst is usually lwer than the nrmal full price f the drug, since ur plan has negtiated lwer csts fr mst drugs. The deductible is the amunt yu must pay fr yur Part D prescriptin drugs befre the plan begins t pay its share. Once yu have paid $$170 fr yur drugs, yu leave the Deductible Stage and mve n t the next drug payment stage, which is the Initial Cverage Stage. Sectin 5 During the Initial Cverage Stage, the plan pays its share f yur drug csts and yu pay yur share Sectin 5.1 What yu pay fr a drug depends n the drug and where yu fill yur prescriptin During the Initial Cverage Stage, the plan pays its share f the cst f yur cvered prescriptin drugs, and yu pay yur share. Yur share f the cst will vary depending n the drug and where yu fill yur prescriptin. The plan has 4 cst-sharing tiers Every drug n the plan s Drug List is in ne f 4 cst-sharing tiers. In general, the higher the cst-sharing tier number, the higher yur cst fr the drug: Cst-Sharing Tier 1 includes generic drugs, which is the lwest tier. Cst-Sharing Tier 2 includes Preferred Brand, which is the next lwest tier. Cst-Sharing Tier 3 includes Nn-Preferred Brand, which is the next t the highest tier. Cst-Sharing Tier 4 includes Specialty drugs, highest tier.

73 Chapter 6: What yu pay fr yur Part D prescriptin drugs 70 T find ut which cst-sharing tier yur drug is in, lk it up in the plan s Drug List. Yur pharmacy chices Hw much yu pay fr a drug depends n whether yu get the drug frm: A retail pharmacy that is in ur plan s netwrk A pharmacy that is nt in the plan s netwrk The plan s mail-rder pharmacy Fr mre infrmatin abut these pharmacy chices and filling yur prescriptins, see Chapter 5 in this bklet and the plan s Pharmacy Directry. Sectin 5.2 A table that shws yur csts fr a ne-mnth (34-day) supply f a drug During the Initial Cverage Stage, yur share f the cst f a cvered drug will be either a cpayment r cinsurance. Cpayment means that yu pay a fixed amunt each time yu fill a prescriptin. Cinsurance means that yu pay a percent f the ttal cst f the drug each time yu fill a prescriptin. As shwn in the table belw, the amunt f the cpayment r cinsurance depends n which cst-sharing tier yur drug is in. Yur share f the cst when yu get a 34-day supply (r less) f a cvered Part D prescriptin drug frm: Cst-Sharing Tier 1 Generic drugs Cst-Sharing Tier 2 Preferred Brand Name Cst-Sharing Tier 3 Nn-Preferred Brand Name Netwrk pharmacy The plan s mail-rder service Netwrk lng-term care pharmacy Out-f-netwrk pharmacy (cverage is limited t certain situatins; see Chapter 5 fr details) $7 cpay $7 cpay $7 cpay $7 cpay $42 cpay $42 cpay $42 cpay $42 cpay $72 cpay $72 cpay $72 cpay $72 cpay

74 Chapter 6: What yu pay fr yur Part D prescriptin drugs 71 Netwrk pharmacy The plan s mail-rder service Netwrk lng-term care pharmacy Out-f-netwrk pharmacy (cverage is limited t certain situatins; see Chapter 5 fr details) Cst-Sharing Tier 4 Specialty Drugs 25% cinsurance 25% cinsurance 25% cinsurance 25% cinsurance Sectin 5.3 A table that shws yur csts fr a lng-term 90-day supply f a drug Fr sme drugs, yu can get a lng-term supply (als called an extended supply ) when yu fill yur prescriptin. This can be up t a 90-day supply. (Fr details n where and hw t get a lng-term supply f a drug, see Chapter 5.) The table belw shws what yu pay when yu get a lng-term 90-day supply f a drug. Yur share f the cst when yu get a lng-term 90-day supply f a cvered Part D prescriptin drug frm: Netwrk pharmacy The plan s mail-rder service Cst-Sharing Tier 1 (Generic drugs) Cst-Sharing Tier 2 (Preferred Brand Name) Cst-Sharing Tier 3 (Nn-Preferred Brand Name) Cst-Sharing Tier 4 (Specialty Drugs) $17.50 cpay $17.50 cpay $105 cpay $105 cpay $180 cpay $180 cpay 25% cinsurance 25% cinsurance Sectin 5.4 Yu stay in the Initial Cverage Stage until yur ttal drug csts fr the year reach $2,840 Yu stay in the Initial Cverage Stage until the ttal amunt fr the prescriptin drugs yu have filled and refilled reaches the $2,840 limit fr the Initial Cverage Stage. Yur ttal drug cst is based n adding tgether what yu have paid and what the plan has paid:

75 Chapter 6: What yu pay fr yur Part D prescriptin drugs 72 What yu have paid fr all the cvered drugs yu have gtten since yu started with yur first drug purchase f the year. (see Sectin 6.2 fr mre infrmatin abut hw Medicare calculates yur ut-fpcket csts) This includes: The $170 yu paid when yu were in the deductible stage. The ttal yu paid as yur share f the cst fr yur drugs during the Initial Cverage Stage. What the plan has paid as its share f the cst fr yur drugs during the Initial Cverage Stage. The Explanatin f Benefits that we send t yu will help yu keep track f hw much yu and the plan have spent fr yur drugs during the year. Many peple d nt reach the $2,840 limit in a year. We will let yu knw if yu reach this $2,840 amunt. If yu d reach this amunt, yu will leave the Initial Cverage Stage and mve n t the Cverage Gap Stage. SECTION 6 During the Cverage Gap Stage, yu receive a discunt n brand name drugs and pay nly 93% f the csts f generic drugs Sectin 6.1 Yu stay in the Cverage Gap Stage until yur ut-f-pcket csts reach $4,550 When yu are in the Cverage Gap Stage, yu pay a discunted price fr brand name drugs. Yu will als pay 93% f the csts f generic drugs. Yu cntinue paying the discunted price fr brand name drugs and 93% f the csts f generic drugs until yur yearly ut-f-pcket payments reach a maximum amunt that Medicare has set. In 2011, that amunt is $4,550. Medicare has rules abut what cunts and what des nt cunt as yur ut-f-pcket csts. When yu reach an ut-f-pcket limit f $4,550, yu leave the Cverage Gap Stage and mve n t the Catastrphic Cverage Stage. Sectin 6.2 Hw Medicare calculates yur ut-f-pcket csts fr prescriptin drugs Here are Medicare s rules that we must fllw when we keep track f yur ut-f-pcket csts fr yur drugs. These payments are included in yur utf-pcket csts When yu add up yur ut-f-pcket csts, yu can include the payments listed belw (as lng as they are fr Part D cvered drugs and yu fllwed the rules fr drug cverage that are explained in Chapter 5 f this bklet): The amunt yu pay fr drugs when yu are in any f the fllwing drug payment stages: The Deductible Stage. The Initial Cverage Stage. The Cverage Gap Stage.

76 Chapter 6: What yu pay fr yur Part D prescriptin drugs 73 Any payments yu made during this calendar year under anther Medicare prescriptin drug plan befre yu jined ur plan. It matters wh pays: If yu make these payments yurself, they are included in yur ut-f-pcket csts. These payments are als included if they are made n yur behalf by certain ther individuals r rganizatins. This includes payments fr yur drugs made by a friend r relative, by mst charities, by AIDS drug assistance prgrams, by the Indian Health Service, r by a State Pharmaceutical Assistance Prgram that is qualified by Medicare. Payments made by Medicare s Extra Help and the Medicare Cverage Gap Discunt Prgram are als included. Mving n t the Catastrphic Cverage Stage: When yu (r thse paying n yur behalf) have spent a ttal f $4,550 in ut-f-pcket csts within the calendar year, yu will mve frm the Cverage Gap Stage t the Catastrphic Cverage Stage. These payments are nt included in yur ut-f-pcket csts When yu add up yur ut-f-pcket csts, yu are nt allwed t include any f these types f payments fr prescriptin drugs: The amunt yu pay fr yur mnthly premium. Drugs yu buy utside the United States and its territries. Drugs that are nt cvered by ur plan. Drugs yu get at an ut-f-netwrk pharmacy that d nt meet the plan s requirements fr ut-f-netwrk cverage. Nn-Part D drugs, including prescriptin drugs cvered by Part A r Part B and ther drugs excluded frm cverage by Medicare. Payments fr yur drugs that are made by grup health plans including emplyer health plans. Payments fr yur drugs that are made by certain insurance plans and gvernmentfunded health prgrams such as TRICARE and the Veteran s Administratin. Payments fr yur drugs made by a third-party with a legal bligatin t pay fr prescriptin csts (fr example, Wrker s Cmpensatin). Reminder: If any ther rganizatin such as the nes listed abve pays part r all f yur ut-f-pcket csts fr drugs, yu are required t tell ur plan. Call Member Services t let us knw (phne numbers are n the cver f this bklet).

77 Chapter 6: What yu pay fr yur Part D prescriptin drugs 74 Hw can yu keep track f yur ut-f-pcket ttal? We will help yu. The Explanatin f Benefits reprt we send t yu includes the current amunt f yur ut-f-pcket csts (Sectin 3 abve tells abut this reprt). When yu reach a ttal f $4,550 in ut-f-pcket csts fr the year, this reprt will tell yu that yu have left the Cverage Gap Stage and have mved n t the Catastrphic Cverage Stage. Make sure we have the infrmatin we need. Sectin 3 abve tells what yu can d t help make sure that ur recrds f what yu have spent are cmplete and up t date. SECTION 7 Sectin 7.1 During the Catastrphic Cverage Stage, the plan pays mst f the cst fr yur drugs Once yu are in the Catastrphic Cverage Stage, yu will stay in this stage fr the rest f the year Yu qualify fr the Catastrphic Cverage Stage when yur ut-f-pcket csts have reached the $4,550 limit fr the calendar year. Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $2.50 cpay cpayment fr a generic drug r a drug that is treated like a generic. Or a $6.30 cpayment fr all ther drugs. Our plan pays the rest f the cst. SECTION 8 Sectin 8.1 Additinal benefits infrmatin Our plan ffers additinal benefits Sectin 8 has been mitted frm this plan. SECTION 9 get them What yu pay fr vaccinatins depends n hw and where yu Sectin 9.1 Our plan has separate cverage fr the vaccine medicatin itself and fr the cst f giving yu the vaccinatin sht. Our plan prvides cverage f a number f vaccines. There are tw parts t ur cverage f vaccinatins: The first part f cverage is the cst f the vaccine medicatin itself. The vaccine is a prescriptin medicatin.

78 Chapter 6: What yu pay fr yur Part D prescriptin drugs 75 The secnd part f cverage is fr the cst f giving yu the vaccinatin sht. (This is smetimes called the administratin f the vaccine.) What d yu pay fr a vaccinatin? What yu pay fr a vaccinatin depends n three things: 1. The type f vaccine (what yu are being vaccinated fr). Sme vaccines are cnsidered medical benefits. Yu can find ut abut yur cverage f these vaccines by ging t Chapter 4, Medical Benefits Chart (what is cvered and what yu pay). Other vaccines are cnsidered Part D drugs. Yu can find these vaccines listed in the plan s List f Cvered Drugs. 2. Where yu get the vaccine medicatin. 3. Wh gives yu the vaccinatin sht. What yu pay at the time yu get the vaccinatin can vary depending n the circumstances. Fr example: Smetimes when yu get yur vaccinatin sht, yu will have t pay the entire cst fr bth the vaccine medicatin and fr getting the vaccinatin sht. Yu can ask ur plan t pay yu back fr ur share f the cst. Other times, when yu get the vaccine medicatin r the vaccinatin sht, yu will pay nly yur share f the cst. T shw hw this wrks, here are three cmmn ways yu might get a vaccinatin sht. Remember yu are respnsible fr all f the csts assciated with vaccines (including their administratin) during the Deductible and Cverage Gap Stage f yur benefit. Situatin 1: Situatin 2: Situatin 3: Yu buy the vaccine at the pharmacy and yu get yur vaccinatin sht at the netwrk pharmacy. (Whether yu have this chice depends n where yu live. Sme states d nt allw pharmacies t administer a vaccinatin.) Yu will have t pay the pharmacy the amunt f yur cpayment fr the vaccine itself. Our plan will pay fr the cst f giving yu the vaccinatin sht. Yu get the vaccinatin at yur dctr s ffice. When yu get the vaccinatin, yu will pay fr the entire cst f the vaccine and its administratin. Yu can then ask ur plan t pay ur share f the cst by using the prcedures that are described in Chapter 7 f this bklet (Asking the plan t pay its share f a bill yu have received fr medical services r drugs). Yu will be reimbursed the amunt yu paid less yur nrmal cpayment fr the vaccine (including administratin). Yu buy the vaccine at yur pharmacy, and then take it t yur dctr s ffice where they give yu the vaccinatin sht.

79 Chapter 6: What yu pay fr yur Part D prescriptin drugs 76 Yu will have t pay the pharmacy the amunt f yur cpayment fr the vaccine itself. When yur dctr gives yu the vaccinatin sht, yu will pay the entire cst fr this service. Yu can then ask ur plan t pay ur share f the cst by using the prcedures described in Chapter 7 f this bklet. Yu will be reimbursed the amunt charged by the dctr fr administering the vaccine Sectin 9.2 Yu may want t call us at Member Services befre yu get a vaccinatin The rules fr cverage f vaccinatins are cmplicated. We are here t help. We recmmend that yu call us first at Member Services whenever yu are planning t get a vaccinatin (phne numbers are n the cver f this bklet). We can tell yu abut hw yur vaccinatin is cvered by ur plan and explain yur share f the cst. We can tell yu hw t keep yur wn cst dwn by using prviders and pharmacies in ur netwrk. If yu are nt able t use a netwrk prvider and pharmacy, we can tell yu what yu need t d t get payment frm us fr ur share f the cst. SECTION 10 D yu have t pay the Part D late enrllment penalty? Sectin 10.1 What is the Part D late enrllment penalty? Yu may pay a financial penalty if yu did nt enrll in a plan ffering Medicare Part D drug cverage when yu first became eligible fr this drug cverage r yu experienced a cntinuus perid f 63 days r mre when yu didn t keep yur prescriptin drug cverage. The amunt f the penalty depends n hw lng yu waited befre yu enrlled in drug cverage after yu became eligible r hw many mnths after 63 days yu went withut drug cverage. The penalty is added t yur mnthly premium. (Members wh chse t pay their premium every three mnths will have the penalty added t their three-mnth premium.) When yu first enrll in Medi-Pak Advantage MA-PD Optin 1 (PFFS), we let yu knw the amunt f the penalty. Yur late enrllment penalty is cnsidered t be part f yur plan premium. If yu d nt pay the part f yur premium that is the late enrllment penalty yu culd be disenrlled fr failure t pay yur plan premium. Sectin 10.2 Hw much is the Part D late enrllment penalty? Medicare determines the amunt f the penalty. Here is hw it wrks: First cunt the number f full mnths that yu delayed enrlling in a Medicare drug plan, after yu were eligible t enrll. Or cunt the number f full mnths in which yu did nt have credible prescriptin drug cverage, if the break in cverage was 63 days r mre. The penalty is 1% fr every mnth that yu didn t have creditable cverage. Fr ur example, let s say it is 14 mnths withut cverage, which will be 14%. Then Medicare determines the amunt f the average mnthly premium fr Medicare drug plans in the natin frm the previus year. Fr 2011, this average premium amunt is $32.34.

80 Chapter 6: What yu pay fr yur Part D prescriptin drugs 77 Yu multiply tgether the tw numbers t get yur mnthly penalty and rund it t the nearest 10 cents. In the example here it wuld be 14% times $32.34, which equals $4.52, which runds t $4.50. This amunt wuld be added t the mnthly premium fr smene with a late enrllment penalty. There are three imprtant things t nte abut this mnthly premium penalty: First, the penalty may change each year, because the average mnthly premium can change each year. If the natinal average premium (as determined by Medicare) increases, yur penalty will increase. Secnd, yu will cntinue t pay a penalty every mnth fr as lng as yu are enrlled in a plan that has Medicare Part D drug benefits. Third, if yu are under 65 and currently receiving Medicare benefits, the late enrllment penalty will reset when yu turn 65. After age 65, yur late enrllment penalty will be based nly n the mnths that yu dn t have cverage after yur initial enrllment perid fr Medicare. If yu are eligible fr Medicare and are under 65, any late enrllment penalty yu are paying will be eliminated when yu attain age 65. After age 65, yur late enrllment penalty is based nly n the mnths yu d nt have cverage after yur Age 65 Initial Enrllment Perid. Sectin 10.3 In sme situatins, yu can enrll late and nt have t pay the penalty Even if yu have delayed enrlling in a plan ffering Medicare Part D cverage when yu were first eligible, smetimes yu d nt have t pay the late enrllment penalty. Yu will nt have t pay a premium penalty fr late enrllment if yu are in any f these situatins: Yu already have prescriptin drug cverage at least as gd as Medicare s standard drug cverage. Medicare calls this creditable drug cverage. Creditable cverage culd include drug cverage frm a frmer emplyer r unin, TRICARE, r the Department f Veterans Affairs. Speak with yur insurer r yur human resurces department t find ut if yur current drug cverage is as at least as gd as Medicare s. If yu were withut creditable cverage, yu can avid paying the late enrllment penalty if yu were withut it fr less than 63 days in a rw. If yu didn t receive enugh infrmatin t knw whether r nt yur previus drug cverage was creditable. Yu lived in an area affected by Hurricane Katrina at the time f the hurricane (August 2005) and yu signed up fr a Medicare prescriptin drug plan by December 31, 2006 and yu have stayed in a Medicare prescriptin drug plan. Yu are receiving Extra Help frm Medicare. Sectin 10.4 What can yu d if yu disagree abut yur late enrllment penalty? If yu disagree abut yur late enrllment penalty, yu can ask us t review the decisin abut yur late enrllment penalty. Call Member Services at the number n the frnt f this bklet t find ut mre abut hw t d this. Imprtant: D nt stp paying yur late enrllment penalty while yu re waiting fr us t review the decisin abut yur late enrllment penalty. If yu d, yu culd be disenrlled fr failure t pay yur plan premiums.

81 Chapter 7: Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs 78 Chapter 7. Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs SECTION 1 Situatins in which yu shuld ask ur plan t pay ur share f the cst f yur cvered services r drugs 79 Sectin 1.1 If yu pay ur plan s share f the cst f yur cvered services r drugs, r if yu receive a bill, yu can ask us fr payment 79 SECTION 2 Hw t ask us t pay yu back r t pay a bill yu have received 80 Sectin 2.1 Hw and where t send us yur request fr payment 80 SECTION 3 We will cnsider yur request fr payment and say yes r n 81 Sectin 3.1 Sectin 3.2 We check t see whether we shuld cver the service r drug and hw much we we 81 If we tell yu that we will nt pay fr the medical care r drug, yu can make an appeal 81 SECTION 4 Other situatins in which yu shuld save yur receipts and send them t the plan 82 Sectin 4.1 In sme cases, yu shuld send yur receipts t the plan t help us track yur ut-f-pcket drug csts 82

82 Chapter 7: Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs 79 SECTION 1 Situatins in which yu shuld ask ur plan t pay ur share f the cst f yur cvered services r drugs Sectin 1.1 If yu pay ur plan s share f the cst f yur cvered services r drugs, r if yu receive a bill, yu can ask us fr payment Smetimes when yu get medical care r prescriptin drug, yu may need t pay the full cst right away. Other times, yu may find that yu have paid mre than yu expected under the cverage rules f the plan. In either case, yu can ask ur plan t pay yu back (paying yu back is ften called reimbursing yu). It is yur right t be paid back by ur plan whenever yu ve paid mre than yur share f the cst fr medical services r drugs that are cvered by ur plan. There may als be times when yu get a bill frm a prvider fr the full cst f medical care yu have received. In many cases, yu shuld send this bill t us instead f paying it. We will lk at the bill and decide whether the services shuld be cvered. If we decide they shuld be cvered, we will pay the prvider directly. Here are examples f situatins in which yu may need t ask ur plan t pay yu back r t pay a bill yu have received: 1. When yu ve received emergency care frm a prvider wh is nt in ur plan s netwrk Yu can receive emergency services frm any prvider, whether r nt the prvider is a part f ur netwrk. When yu receive emergency care frm a prvider wh is nt part f ur netwrk, yu are nly respnsible fr paying yur share f the cst, nt fr the entire cst. Yu shuld ask the prvider t bill the plan fr ur share f the cst. If yu pay the entire amunt yurself at the time yu receive the care, yu need t ask us t pay yu back fr ur share f the cst. Send us the bill, alng with dcumentatin f any payments yu have made. At times yu may get a bill frm the prvider asking fr payment that yu think yu d nt we. Send us this bill, alng with dcumentatin f any payments yu have already made. If the prvider is wed anything, we will pay the prvider directly. If yu have already paid mre than yur share f the cst f the service, we will determine hw much yu wed and pay yu back fr ur share f the cst. 2. When a netwrk prvider sends yu a bill yu think yu shuld nt pay Netwrk prviders shuld always bill the plan directly, and ask yu nly fr yur share f the cst. But smetimes they make mistakes, and ask yu t pay mre than yur share. Whenever yu get a bill frm a netwrk prvider that yu think is mre than yu shuld pay, send us the bill. We will cntact the prvider directly and reslve the billing prblem. If yu have already paid a bill t a netwrk prvider, but yu feel that yu paid t much, send us the bill alng with dcumentatin f any payment yu have made and ask us t pay yu back the difference between the amunt yu paid and the amunt yu wed under the plan.

83 Chapter 7: Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs When yu use an ut-f-netwrk pharmacy t get a prescriptin filled If yu g t an ut-f-netwrk pharmacy and try t use yur membership card t fill a prescriptin, the pharmacy may nt be able t submit the claim directly t us. When that happens, yu will have t pay the full cst f yur prescriptin. Save yur receipt and send a cpy t us when yu ask us t pay yu back fr ur share f the cst. 4. When yu pay the full cst fr a prescriptin because yu dn t have yur plan membership card with yu If yu d nt have yur plan membership card with yu, yu can ask the pharmacy t call the plan r lk up yur enrllment infrmatin. Hwever, if the pharmacy cannt get the enrllment infrmatin they need right away, yu may need t pay the full cst f the prescriptin yurself. Save yur receipt and send a cpy t us when yu ask us t pay yu back fr ur share f the cst. 5. When yu pay the full cst fr a prescriptin in ther situatins Yu may pay the full cst f the prescriptin because yu find that the drug is nt cvered fr sme reasn. Fr example, the drug may nt be n the plan s List f Cvered Drugs (Frmulary); r it culd have a requirement r restrictin that yu didn t knw abut r dn t think shuld apply t yu. If yu decide t get the drug immediately, yu may need t pay the full cst fr it. Save yur receipt and send a cpy t us when yu ask us t pay yu back. In sme situatins, we may need t get mre infrmatin frm yur dctr in rder t pay yu back fr ur share f the cst. All f the examples abve are types f cverage decisins. This means that if we deny yur request fr payment, yu can appeal ur decisin. Chapter 9 f this bklet (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) has infrmatin abut hw t make an appeal. SECTION 2 Hw t ask us t pay yu back r t pay a bill yu have received Sectin 2.1 Hw and where t send us yur request fr payment Send us yur request fr payment, alng with yur bill and dcumentatin f any payment yu have made. It s a gd idea t make a cpy f yur bill and receipts fr yur recrds. T make sure yu are giving us all the infrmatin we need t make a decisin, yu can fill ut ur claim frm t make yur request fr payment. Yu dn t have t use the frm, but it s helpful fr ur plan t prcess the infrmatin faster. Either dwnlad a cpy f the frm frm ur website ( r call Member Services and ask fr the frm. The phne numbers fr Member Services are n the cver f this bklet.

84 Chapter 7: Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs 81 Mail yur request fr payment tgether with any bills r receipts fr prescriptin drug claims t us at this address: Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Claims Department P. O. Bx Phenix, AZ Medi-Pak Advantage MA-PD Optin 1 (PFFS) P.O. Bx 2181 Little Rck, AR Yu may als call ur plan t request payment. Fr details, g t Chapter 2, Sectin 1 and lk fr the sectin called, Where t send a request that asks us t pay fr ur share f the cst fr medical care r a drug yu have received. Please be sure t cntact Member Services if yu have any questins. If yu dn t knw what yu we, r yu receive bills and yu dn t knw what t d abut thse bills, we can help. Yu can als call if yu want t give us mre infrmatin abut a request fr payment yu have already sent t us. SECTION 3 We will cnsider yur request fr payment and say yes r n Sectin 3.1 We check t see whether we shuld cver the service r drug and hw much we we When we receive yur request fr payment, we will let yu knw if we need any additinal infrmatin frm yu. Otherwise, we will cnsider yur request and decide whether t pay it and hw much we we. If we decide that the medical care r drug is cvered and yu fllwed all the rules fr getting the care r drug, we will pay fr ur share f the cst. If yu have already paid fr the service r drug, we will mail yur reimbursement f ur share f the cst t yu. If yu have nt paid fr the service r drug yet, we will mail the payment directly t the prvider. (Chapter 3 explains the rules yu need t fllw fr getting yur medical services. (Chapter 5 explains the rules yu need t fllw fr getting yur Part D prescriptin drugs.) If we decide that the medical care r drug is nt cvered, r yu did nt fllw all the rules, we will nt pay fr ur share f the cst. Instead, we will send yu a letter that explains the reasns why we are nt sending the payment yu have requested and yur rights t appeal that decisin. Sectin 3.2 If we tell yu that we will nt pay fr the medical care r drug, yu can make an appeal If yu think we have made a mistake in turning yu dwn yur request fr payment, yu can make an appeal. If yu make an appeal, it means yu are asking us t change the decisin we made when we turned dwn yur request fr payment. Fr the details n hw t make this appeal, g t Chapter 9 f this bklet (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). The appeals prcess is a legal prcess with detailed prcedures and imprtant deadlines. If making an appeal is new t yu, yu will find it helpful t start by

85 Chapter 7: Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs 82 reading Sectin 4 f Chapter 9. Sectin 4 is an intrductry sectin that explains the prcess fr cverage decisins and appeals and gives definitins f terms such as appeal. Then after yu have read Sectin 4, yu can g t the sectin in Chapter 9 that tells what t d fr yur situatin: If yu want t make an appeal abut getting paid back fr a medical service, g t Sectin 5.4 in Chapter 9. If yu want t make an appeal abut getting paid back fr a drug, g t Sectin 6.6 f Chapter 9. SECTION 4 Other situatins in which yu shuld save yur receipts and send them t the plan Sectin 4.1 In sme cases, yu shuld send yur receipts t the plan t help us track yur ut-f-pcket drug csts There are sme situatins when yu shuld let us knw abut payments yu have made fr yur drugs. In these cases, yu are nt asking us fr payment. Instead, yu are telling us abut yur payments s that we can calculate yur ut-f-pcket csts crrectly. This may help yu t qualify fr the Catastrphic Cverage Stage mre quickly. Here are tw situatins when yu shuld send us receipts t let us knw abut payments yu have made fr yur drugs: 1. When yu buy the drug fr a price that is lwer than the plan s price Smetimes when yu are in the Deductible Stage and Cverage Gap Stage yu can buy yur drug at a netwrk pharmacy fr a price that is lwer than the plan s price. Fr example, a pharmacy might ffer a special price n the drug. Or yu may have a discunt card that is utside the plan s benefit that ffers a lwer price. Unless special cnditins apply, yu must use a netwrk pharmacy in these situatins and yur drug must be n ur Drug List. Save yur receipt and send a cpy t us s that we can have yur ut-f-pcket expenses cunt tward qualifying yu fr the Catastrphic Cverage Stage. Please nte: If yu are in the Deductible Stage and Cverage Gap Stage, the plan will nt pay fr any share f these drug csts. But sending the receipt allws us t calculate yur ut-f-pcket csts crrectly and may help yu qualify fr the Catastrphic Cverage Stage mre quickly. 2. When yu get a drug thrugh a patient assistance prgram ffered by a drug manufacturer Sme members are enrlled in a patient assistance prgram ffered by a drug manufacturer that is utside the plan benefits. If yu get any drugs thrugh a prgram ffered by a drug manufacturer, yu may pay a cpayment t the patient assistance prgram. Save yur receipt and send a cpy t us s that we can have yur ut-f-pcket expenses cunt tward qualifying yu fr the Catastrphic Cverage Stage. Please nte: Because yu are getting yur drug thrugh the patient assistance prgram and nt thrugh the plan s benefits, the plan will nt pay fr any share f these drug csts. But sending the

86 Chapter 7: Asking yur plan t pay its share f a bill yu have received fr cvered services r drugs 83 receipt allws us t calculate yur ut-f-pcket csts crrectly and may help yu qualify fr the Catastrphic Cverage Stage mre quickly. Since yu are nt asking fr payment in the tw cases described abve, these situatins are nt cnsidered cverage decisins. Therefre, yu cannt make an appeal if yu disagree with ur decisin.

87 Chapter 8: Yur rights and respnsibilities 84 Chapter 8. Yur rights and respnsibilities SECTION 1 Our plan must hnr yur rights as a member f the plan 85 Sectin 1.1 We must prvide infrmatin in a way that wrks fr yu 85 Sectin 1.2 We must treat yu with fairness and respect at all times 85 Sectin 1.3 We must ensure that yu get timely access t yur cvered services and drugs 85 Sectin 1.4 We must prtect the privacy f yur persnal health infrmatin 86 Sectin 1.5 We must give yu infrmatin abut the plan, its netwrk f prviders, and yur cvered services 86 Sectin 1.6 We must supprt yur right t make decisins abut yur care 88 Sectin 1.7 Sectin 1.8 Yu have the right t make cmplaints and t ask us t recnsider decisins we have made 89 What can yu d if yu think yu are being treated unfairly r yur rights are nt being respected? 89 Sectin 1.9 Hw t get mre infrmatin abut yur rights 90 SECTION 2 Yu have sme respnsibilities as a member f the plan 90 Sectin 2.1 What are yur respnsibilities? 90

88 Chapter 8: Yur rights and respnsibilities 85 SECTION 1 Our plan must hnr yur rights as a member f the plan Sectin 1.1 We must prvide infrmatin in a way that wrks fr yu in an audi CD (Cmpact Disc) frmat T get infrmatin frm us in a way that wrks fr yu, please call Member Services (phne numbers are n the frnt cver). Our plan has peple and translatin services available t answer questins frm nn-english speaking members. We can als give yu infrmatin in an audi CD (Cmpact Disc) frmat if yu need it. If yu are eligible fr Medicare because f disability, we are required t give yu infrmatin abut the plan s benefits that is accessible and apprpriate fr yu. If yu have any truble getting infrmatin frm ur plan because f prblems related t language r disability, please call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week, and tell them that yu want t file a cmplaint. TTY users call Sectin 1.2 We must treat yu with fairness and respect at all times Our plan must bey laws that prtect yu frm discriminatin r unfair treatment. We d nt discriminate based n a persn s race, disability, religin, sex, health, ethnicity, creed (beliefs), age, r natinal rigin. If yu want mre infrmatin r have cncerns abut discriminatin r unfair treatment, please call the Department f Health and Human Services Office fr Civil Rights (TTY ) r yur lcal Office fr Civil Rights. If yu have a disability and need help with access t care, please call us at Member Services (phne numbers are n the cver f this bklet). If yu have a cmplaint, such as a prblem with wheelchair access, Member Services can help. Sectin 1.3 We must ensure that yu get timely access t yur cvered services and drugs Yu may seek care frm any prvider in the United States, if the prvider agrees t accept ur plan s terms and cnditins f payment prir t prviding services t yu and is eligible t prvide services under Original Medicare, as described in Chapter 3, Sectin 1.2. Yu shuld always (except pssibly in emergencies) shw the prvider yur PFFS plan membership card. As a plan member, yu have the right t get appintments and cvered services frm the plan s netwrk f prviders within a reasnable amunt f time. Our plan has signed cntracts with sme prviders t deliver cvered services t members in ur plan. These prviders are ur netwrk prviders. Chapter 3, Sectin 1.2 describes the rules fr getting cvered services using ur netwrk prviders. Yu als have the right t get yur prescriptins filled r refilled at any f ur netwrk pharmacies withut lng delays. If yu think that yu are nt getting yur medical care r Part D drugs within a reasnable amunt f time, Chapter 9 f this bklet tells what yu can d.

89 Chapter 8: Yur rights and respnsibilities 86 Sectin 1.4 We must prtect the privacy f yur persnal health infrmatin Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Yur persnal health infrmatin includes the persnal infrmatin yu gave us when yu enrlled in this plan as well as yur medical recrds and ther medical and health infrmatin. The laws that prtect yur privacy give yu rights related t getting infrmatin and cntrlling hw yur health infrmatin is used. We give yu a written ntice, called a Ntice f Privacy Practice that tells abut these rights and explains hw we prtect the privacy f yur health infrmatin. Hw d we prtect the privacy f yur health infrmatin? We make sure that unauthrized peple dn t see r change yur recrds. In mst situatins, if we give yur health infrmatin t anyne wh isn t prviding yur care r paying fr yur care, we are required t get written permissin frm yu first. Written permissin can be given by yu r by smene yu have given legal pwer t make decisins fr yu. There are certain exceptins that d nt require us t get yur written permissin first. These exceptins are allwed r required by law. Fr example, we are required t release health infrmatin t gvernment agencies that are checking n quality f care. Because yu are a member f ur plan thrugh Medicare, we are required t give Medicare yur health infrmatin including infrmatin abut yur Part D prescriptin drugs. If Medicare releases yur infrmatin fr research r ther uses, this will be dne accrding t Federal statutes and regulatins. Yu can see the infrmatin in yur recrds and knw hw it has been shared with thers Yu have the right t lk at yur medical recrds held at the plan, and t get a cpy f yur recrds. We are allwed t charge yu a fee fr making cpies. Yu als have the right t ask us t make additins r crrectins t yur medical recrds. If yu ask us t d this, we will cnsider yur request and decide whether the changes shuld be made. Yu have the right t knw hw yur health infrmatin has been shared with thers fr any purpses that are nt rutine. If yu have questins r cncerns abut the privacy f yur persnal health infrmatin, please call Member Services (phne numbers are n the cver f this bklet). Sectin 1.5 We must give yu infrmatin abut the plan, its netwrk f prviders, and yur cvered services As a member f ur plan, yu have the right t get several kinds f infrmatin frm us. (As explained abve in Sectin 1.1, yu have the right t get infrmatin frm us in a way that wrks fr yu. This includes getting the infrmatin in audi CD (cmpact disc).

90 Chapter 8: Yur rights and respnsibilities 87 If yu want any f the fllwing kinds f infrmatin, please call Member Services (phne numbers are n the cver f this bklet): Infrmatin abut ur plan. This includes, fr example, infrmatin abut the plan s financial cnditin. It als includes infrmatin abut the number f appeals made by members and the plan s perfrmance ratings, including hw it has been rated by plan members and hw it cmpares t ther Medicare Advantage health plans. Infrmatin abut ur netwrk prviders including ur netwrk pharmacies. Fr example, yu have the right t get infrmatin frm us abut the qualificatins f the prviders and pharmacies in ur netwrk and hw we pay the prviders in ur netwrk. Fr a list f the prviders in the plan s netwrk, see the Medi-Pak Advantage (PFFS) Prvider Directry. Fr a list f the pharmacies in the plan s netwrk, see the Medi-Pak Advantage (PFFS) Pharmacy Directry. Fr mre detailed infrmatin abut ur prviders r pharmacies yu can call Member Services (phne numbers are n the cver f this bklet) r visit ur website at Infrmatin abut yur cverage and rules yu must fllw in using yur cverage. In Chapters 3 and 4 f this bklet, we explain what medical services are cvered fr yu, any restrictins t yur cverage, and what rules yu must fllw t get yur cvered medical services. T get the details n yur Part D prescriptin drug cverage, see Chapters 5 and 6 f this bklet plus the plan s Medi-Pak Advantage (PFFS) Frmulary. These chapters, tgether with the Medi- Pak Advantage (PFFS) Frmulary, tell yu what drugs are cvered and explain the rules yu must fllw and the restrictins t yur cverage fr certain drugs. If yu have questins abut the rules r restrictins, please call Member Services (phne numbers are n the cver f this bklet). Infrmatin abut why smething is nt cvered and what yu can d abut it. If a medical service r Part D drug is nt cvered fr yu, r if yur cverage is restricted in sme way, yu can ask us fr a written explanatin. Yu have the right t this explanatin even if yu received the medical service r drug frm an ut-f-netwrk prvider r pharmacy. If yu are nt happy r if yu disagree with a decisin we make abut what medical care r Part D drug is cvered fr yu, yu have the right t ask us t change the decisin. Fr details n what t d if smething is nt cvered fr yu in the way yu think it shuld be cvered, see Chapter 9 f this bklet. It gives yu the details abut hw t ask the plan fr a decisin abut yur cverage and hw t make an appeal if yu want us t change ur decisin. Chapter 9 als tells abut hw t make a cmplaint abut quality f care, waiting times, and ther cncerns. If yu want t ask ur plan t pay ur share f a bill yu have received fr medical care r a Part D prescriptin drug, see Chapter 7 f this bklet. Sectin 1.6 We must supprt yur right t make decisins abut yur care

91 Chapter 8: Yur rights and respnsibilities 88 Yu have the right t knw yur treatment ptins and participate in decisins abut yur health care Yu have the right t get full infrmatin frm yur dctrs and ther health care prviders when yu g fr medical care. Yur prviders must explain yur medical cnditin and yur treatment chices in a way that yu can understand. Yu als have the right t participate fully in decisins abut yur health care. T help yu make decisins with yur dctrs abut what treatment is best fr yu, yur rights include the fllwing: T knw abut all f yur chices. This means that yu have the right t be tld abut all f the treatment ptins that are recmmended fr yur cnditin, n matter what they cst r whether they are cvered by ur plan. It als includes being tld abut prgrams ur plan ffers t help members manage their medicatins and use drugs safely. T knw abut the risks. Yu have the right t be tld abut any risks invlved in yur care. Yu must be tld in advance if any prpsed medical care r treatment is part f a research experiment. Yu always have the chice t refuse any experimental treatments. The right t say n. Yu have the right t refuse any recmmended treatment. This includes the right t leave a hspital r ther medical facility, even if yur dctr advises yu nt t leave. Yu als have the right t stp taking yur medicatin. Of curse, if yu refuse treatment r stp taking medicatin, yu accept full respnsibility fr what happens t yur bdy as a result. T receive an explanatin if yu are denied cverage fr care. Yu have the right t receive an explanatin frm us if a prvider has denied care that yu believe yu shuld receive. T receive this explanatin, yu will need t ask us fr a cverage decisin. Chapter 9 f this bklet tells hw t ask the plan fr a cverage decisin. Yu have the right t give instructins abut what is t be dne if yu are nt able t make medical decisins fr yurself Smetimes peple becme unable t make health care decisins fr themselves due t accidents r serius illness. Yu have the right t say what yu want t happen if yu are in this situatin. This means that, if yu want t, yu can: Fill ut a written frm t give smene the legal authrity t make medical decisins fr yu if yu ever becme unable t make decisins fr yurself. Give yur dctrs written instructins abut hw yu want them t handle yur medical care if yu becme unable t make decisins fr yurself. The legal dcuments that yu can use t give yur directins in advance in these situatins are called advance directives. There are different types f advance directives and different names fr them. Dcuments called living will and pwer f attrney fr health care are examples f advance directives. If yu want t use an advance directive t give yur instructins, here is what t d: Get the frm. If yu want t have an advance directive, yu can get a frm frm yur lawyer, frm a scial wrker, r frm sme ffice supply stres. Yu can smetimes get advance directive frms frm rganizatins that give peple infrmatin abut Medicare.

92 Chapter 8: Yur rights and respnsibilities 89 Fill it ut and sign it. Regardless f where yu get this frm, keep in mind that it is a legal dcument. Yu shuld cnsider having a lawyer help yu prepare it. Give cpies t apprpriate peple. Yu shuld give a cpy f the frm t yur dctr and t the persn yu name n the frm as the ne t make decisins fr yu if yu can t. Yu may want t give cpies t clse friends r family members as well. Be sure t keep a cpy at hme. If yu knw ahead f time that yu are ging t be hspitalized, and yu have signed an advance directive, take a cpy with yu t the hspital. If yu are admitted t the hspital, they will ask yu whether yu have signed an advance directive frm and whether yu have it with yu. If yu have nt signed an advance directive frm, the hspital has frms available and will ask if yu want t sign ne. Remember, it is yur chice whether yu want t fill ut an advance directive (including whether yu want t sign ne if yu are in the hspital). Accrding t law, n ne can deny yu care r discriminate against yu based n whether r nt yu have signed an advance directive. What if yur instructins are nt fllwed? If yu have signed an advance directive, and yu believe that a dctr r hspital hasn t fllwed the instructins in it, yu may file a cmplaint with Arkansas Department f Health and Human Services, Divisin f Medical Services, Dnaghey Plaza Suth, P.O. Bx 1437 Slt 1100, Little Rck, AR Sectin 1.7 Yu have the right t make cmplaints and t ask us t recnsider decisins we have made If yu have any prblems r cncerns abut yur cvered services r care, Chapter 9 f this bklet tells what yu can d. It gives the details abut hw t deal with all types f prblems and cmplaints. As explained in Chapter 9, what yu need t d t fllw up n a prblem r cncern depends n the situatin. Yu might need t ask ur plan t make a cverage decisin fr yu, make an appeal t us t change a cverage decisin, r make a cmplaint. Whatever yu d ask fr a cverage decisin, make an appeal, r make a cmplaint we are required t treat yu fairly. Yu have the right t get a summary f infrmatin abut the appeals and cmplaints that ther members have filed against ur plan in the past. T get this infrmatin, please call Member Services (phne numbers are n the cver f this bklet). Sectin 1.8 What can yu d if yu think yu are being treated unfairly r yur rights are nt being respected? If it is abut discriminatin, call the Office fr Civil Rights If yu think yu have been treated unfairly r yur rights have nt been respected due t yur race, disability, religin, sex, health, ethnicity, creed (beliefs), age, r natinal rigin, yu shuld call the Department f Health and Human Services Office fr Civil Rights at r TTY , r call yur lcal Office fr Civil Rights.

93 Chapter 8: Yur rights and respnsibilities 90 Is it abut smething else? If yu think yu have been treated unfairly r yur rights have nt been respected, and it s nt abut discriminatin, yu can get help dealing with the prblem yu are having: Yu can call Member Services (phne numbers are n the cver f this bklet). Yu can call the State Health Insurance Assistance Prgram. Fr details abut this rganizatin and hw t cntact it, g t Chapter 2, Sectin 3. Sectin 1.9 Hw t get mre infrmatin abut yur rights There are several places where yu can get mre infrmatin abut yur rights: Yu can call Member Services (phne numbers are n the cver f this bklet). Yu can call the State Health Insurance Assistance Prgram. Fr details abut this rganizatin and hw t cntact it, g t Chapter 2, Sectin 3. Yu can cntact Medicare. Yu can visit the Medicare website ( t read r dwnlad the publicatin Yur Medicare Rights & Prtectins. Or, yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call SECTION 2 Yu have sme respnsibilities as a member f the plan Sectin 2.1 What are yur respnsibilities? Things yu need t d as a member f the plan are listed belw. If yu have any questins, please call Member Services (phne numbers are n the cver f this bklet). We re here t help. Get familiar with yur cvered services and the rules yu must fllw t get these cvered services. Use this Evidence f Cverage bklet t learn what is cvered fr yu and the rules yu need t fllw t get yur cvered services. Chapters 3 and 4 give the details abut yur medical services, including what is cvered, what is nt cvered, rules t fllw, and what yu pay. Chapters 5 and 6 give the details abut yur cverage fr Part D prescriptin drugs. If yu have any ther health insurance cverage r prescriptin drug cverage in additin t ur plan, yu are required t tell us. Please call Member Services t let us knw. We are required t fllw rules set by Medicare t make sure that yu are using all f yur cverage in cmbinatin when yu get yur cvered services frm ur plan. This is called crdinatin f benefits because it invlves crdinating the health and drug benefits yu get frm ur plan with any ther health and drug benefits available t yu. We ll help yu with it.

94 Chapter 8: Yur rights and respnsibilities 91 Tell yur dctr and ther health care prviders that yu are enrlled in ur plan. Shw yur plan membership card whenever yu get yur medical care r Part D prescriptin drugs. Help yur dctrs and ther prviders help yu by giving them infrmatin, asking questins, and fllwing thrugh n yur care. T help yur dctrs and ther health prviders give yu the best care, learn as much as yu are able t abut yur health prblems and give them the infrmatin they need abut yu and yur health. Fllw the treatment plans and instructins that yu and yur dctrs agree upn. If yu have any questins, be sure t ask. Yur dctrs and ther health care prviders are suppsed t explain things in a way yu can understand. If yu ask a questin and yu dn t understand the answer yu are given, ask again. Be cnsiderate. We expect all ur members t respect the rights f ther patients. We als expect yu t act in a way that helps the smth running f yur dctr s ffice, hspitals, and ther ffices. Pay what yu we. As a plan member, yu are respnsible fr these payments: Yu must pay yur plan premiums t cntinue being a member f ur plan. In rder t be eligible fr ur plan, yu must maintain yur eligibility fr Medicare Part A and Part B. Fr that reasn, sme plan members must pay a premium fr Medicare Part A and mst plan members must pay a premium fr Medicare Part B t remain a member f the plan. Fr sme f yur medical services r drugs cvered by the plan, yu must pay yur share f the cst when yu get the service r drug. This will be a cpayment (a fixed amunt) r cinsurance (a percentage f the ttal cst). Chapter 4 tells what yu must pay fr yur medical services. Chapter 6 tells what yu must pay fr yur Part D prescriptin drugs. If yu get any medical services r drugs that are nt cvered by ur plan r by ther insurance yu may have, yu must pay the full cst. Tell us if yu mve. If yu are ging t mve, it s imprtant t tell us right away. Call Member Services (phne numbers are n the cver f this bklet). If yu mve utside f ur plan service area, yu cannt remain a member f ur plan. (Chapter 1 tells abut ur service area.) We can help yu figure ut whether yu are mving utside ur service area. If yu are leaving ur service area, we can let yu knw if we have a plan in yur new area. If yu mve within ur service area, we still need t knw s we can keep yur membership recrd up t date and knw hw t cntact yu. Call member services fr help if yu have questins r cncerns. We als welcme any suggestins yu may have fr imprving ur plan. Phne numbers and calling hurs fr Member Services are n the cver f this bklet. Fr mre infrmatin n hw t reach us, including ur mailing address, please see Chapter 2

95 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 92 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) BACKGROUND SECTION 1 Intrductin 95 Sectin 1.1 What t d if yu have a prblem r cncern 95 Sectin 1.2 What abut the legal terms? 95 SECTION 2 Yu can get help frm gvernment rganizatins that are nt cnnected with us 95 Sectin 2.1 Where t get mre infrmatin and persnalized assistance 95 SECTION 3 T deal with yur prblem, which prcess shuld yu use? 96 Sectin 3.1 Shuld yu use the prcess fr cverage decisins and appeals? Or shuld yu use the prcess fr making cmplaints? 96 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide t the basics f cverage decisins and appeals 97 Sectin 4.1 Asking fr cverage decisins and making appeals: the big picture 97 Sectin 4.2 Hw t get help when yu are asking fr a cverage decisin r making an appeal 97 Sectin 4.3 Which sectin f this chapter gives the details fr yur situatin? 98 SECTION 5 Yur medical care: Hw t ask fr a cverage decisin 98 Sectin 5.1 This sectin tells what t d if yu have prblems getting cverage fr medical care r if yu want us t pay yu back fr ur share f the cst f yur care 99 Sectin 5.2 Sectin 5.3 Step-by-step: Hw t ask fr a cverage decisin (hw t ask ur plan t authrize r prvide the medical care cverage yu want) 100 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a medical care cverage decisin made by ur plan) 102 Sectin 5.4 Step-by-step: Hw t make a Level 2 Appeal 104 Sectin 5.5 What if yu are asking ur plan t pay yu fr ur share f a bill yu have received fr medical care? 106 SECTION 6 Yur Part D prescriptin drugs: Hw t ask fr a

96 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 93 cverage decisin r make an appeal 107 Sectin 6.1 This sectin tells yu what t d if yu have prblems getting a Part D drug r yu want us t pay yu back fr a Part D drug 107 Sectin 6.2 What is an exceptin? 108 Sectin 6.3 Imprtant things t knw abut asking fr exceptins 110 Sectin 6.4 Step-by-step: Hw t ask fr a cverage decisin, including an exceptin 110 Sectin 6.5 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a cverage decisin made by ur plan) 112 Sectin 6.6 Step-by-step: Hw t make a Level 2 Appeal 114 SECTION 7 Hw t ask us t cver a lnger hspital stay if yu think the dctr is discharging yu t sn 116 Sectin 7.1 Sectin 7.2 Sectin 7.3 During yur hspital stay, yu will get a written ntice frm Medicare that tells abut yur rights 116 Step-by-step: Hw t make a Level 1 Appeal t change yur hspital discharge date 117 Step-by-step: Hw t make a Level 2 Appeal t change yur hspital discharge date 120 Sectin 7.4 What if yu miss the deadline fr making yur Level 1 Appeal? 121 SECTION 8 Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn 123 Sectin 8.1 This sectin is abut three services nly: Hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services 123 Sectin 8.2 We will tell yu in advance when yur cverage will be ending 123 Sectin 8.3 Sectin 8. Step-by-step: Hw t make a Level 1 Appeal t have ur plan cver yur care fr a lnger time 124 Step-by-step: Hw t make a Level 2 Appeal t have ur plan cver yur care fr a lnger time 126 Sectin 8.5 What if yu miss the deadline fr making yur Level 1 Appeal? 125 SECTION 9 Taking yur appeal t Level 3 and beynd 129 Sectin 9.1 Levels f Appeal 3, 4, and 5 fr Medical Service Appeals 129 Sectin 9.2 Levels f Appeal 3, 4, and 5 fr Part D Drug Appeal 131

97 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 94 MAKING COMPLAINTS SECTION 10 Hw t make a cmplaint abut quality f care, waiting times, custmer service, r ther cncerns 132 Sectin 10.1 What kinds f prblems are handled by the cmplaint prcess? 132 Sectin 10.2 The frmal name fr making a cmplaint is filing a grievance 134 Sectin 10.3 Step-by-step: Making a cmplaint 134 Sectin 10.4 Yu can als make cmplaints abut quality f care t the Quality Imprvement Organizatin 135

98 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 95 BACKGROUND SECTION 1 Intrductin Sectin 1.1 What t d if yu have a prblem r cncern This chapter explains tw types f prcesses fr handling prblems and cncerns: Fr sme types f prblems, yu need t use the prcess fr cverage decisins and making appeals. Fr ther types f prblems yu need t use the prcess fr making cmplaints. Bth f these prcesses have been apprved by Medicare. T ensure fairness and prmpt handling f yur prblems, each prcess has a set f rules, prcedures, and deadlines that must be fllwed by us and by yu. Which ne d yu use? That depends n the type f prblem yu are having. The guide in Sectin 3 will help yu identify the right prcess t use. Sectin 1.2 What abut the legal terms? There are technical legal terms fr sme f the rules, prcedures, and types f deadlines explained in this chapter. Many f these terms are unfamiliar t mst peple and can be hard t understand. T keep things simple, this chapter explains the legal rules and prcedures using mre cmmn wrds in place f certain legal terms. Fr example, this chapter generally says making a cmplaint rather than filing a grievance, cverage decisin rather than rganizatin determinatin r cverage determinatin, and Independent Review Organizatin instead f Independent Review Entity. It als uses abbreviatins as little as pssible. Hwever, it can be helpful and smetimes quite imprtant fr yu t knw the crrect legal terms fr the situatin yu are in. Knwing which terms t use will help yu cmmunicate mre clearly and accurately when yu are dealing with yur prblem and get the right help r infrmatin fr yur situatin. T help yu knw which terms t use, we include legal terms when we give the details fr handling specific types f situatins. SECTION 2 Yu can get help frm gvernment rganizatins that are nt cnnected with us Sectin 2.1 Where t get mre infrmatin and persnalized assistance Smetimes it can be cnfusing t start r fllw thrugh the prcess fr dealing with a prblem. This can be especially true if yu d nt feel well r have limited energy. Other times, yu may nt have the knwledge yu need t take the next step. Perhaps bth are true fr yu. Get help frm an independent gvernment rganizatin We are always available t help yu. But in sme situatins yu may als want help r guidance frm smene wh is nt cnnected with us. Yu can always cntact yur State Health Insurance Assistance Prgram (SHIP). This gvernment prgram has trained cunselrs in every state. The prgram is nt

99 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 96 cnnected with ur plan r with any insurance cmpany r health plan. The cunselrs at this prgram can help yu understand which prcess yu shuld use t handle a prblem yu are having. They can als answer yur questins, give yu mre infrmatin, and ffer guidance n what t d. The services f SHIP cunselrs are free. Yu will find phne numbers in Chapter 2, Sectin 3 f this bklet. Yu can als get help and infrmatin frm Medicare Fr mre infrmatin and help in handling a prblem, yu can als cntact Medicare. Here are tw ways t get infrmatin directly frm Medicare: Yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can visit the Medicare website ( SECTION 3 T deal with yur prblem, which prcess shuld yu use? Sectin 3.1 Shuld yu use the prcess fr cverage decisins and appeals? Or shuld yu use the prcess fr making cmplaints? If yu have a prblem r cncern and yu want t d smething abut it, yu dn t need t read this whle chapter. Yu just need t find and read the parts f this chapter that apply t yur situatin. The guide that fllws will help. T figure ut which part f this chapter tells what t d fr yur prblem r cncern. START HERE Is yur prblem r cncern abut yur benefits and cverage? (This includes prblems abut whether particular medical care r prescriptin drugs are cvered r nt, the way in which they are cvered, and prblems related t payment fr medical care r prescriptin drugs. YES q G n t the next sectin f this chapter, Sectin 4: A Guide t the basics f cverage decisins and making appeals. NO q Skip ahead t Sectin 10 at the end f this chapter: Hw t make a cmplaint abut quality f care, waiting times, custmer service r ther cncerns.

100 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 97 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide t the basics f cverage decisins and appeals Sectin 4.1 Asking fr cverage decisins and making appeals: the big picture The prcess fr cverage decisins and making appeals deals with prblems related t yur benefits and cverage fr medical services and prescriptin drugs, including prblems related t payment. This is the prcess yu use fr issues such as whether smething is cvered r nt and the way in which smething is cvered. Asking fr cverage decisins A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur medical services r drugs. We and/r yur dctr make a cverage decisin fr yu whenever yu g t a dctr fr medical care. Yu can als cntact the plan and ask fr a cverage decisin. Fr example, if yu want t knw if we will cver a medical service befre yu receive it, yu can ask us t make a cverage decisin fr yu. We are making a cverage decisin fr yu whenever we decide what is cvered fr yu and hw much we pay. In sme cases we might decide a service r drug is nt cvered r is n lnger cvered by Medicare fr yu. If yu disagree with this cverage decisin, yu can make an appeal. Making an appeal If we make a cverage decisin and yu are nt satisfied with this decisin, yu can appeal the decisin. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu make an appeal, we review the cverage decisin we have made t check t see if we were fllwing all f the rules prperly. When we have cmpleted the review we give yu ur decisin. If we say n t all r part f yur Level 1 Appeal, yu can g n t a Level 2 Appeal. The Level 2 Appeal is cnducted by an independent rganizatin that is nt cnnected t ur plan. If yu are nt satisfied with the decisin at the Level 2 Appeal, yu may be able t cntinue thrugh several mre levels f appeal. Sectin 4.2 Hw t get help when yu are asking fr a cverage decisin r making an appeal Wuld yu like sme help? Here are resurces yu may wish t use if yu decide t ask fr any kind f cverage decisin r appeal a decisin: Yu can call us at Member Services (phne numbers are n the cver). T get free help frm an independent rganizatin that is nt cnnected with ur plan, cntact yur State Health Insurance Assistance Prgram (see Sectin 2 f this chapter). Yur dctr r ther prvider can make a request fr yu. Yur dctr r ther prvider can request a cverage decisin r a Level 1 Appeal n yur behalf. T request any appeal after Level 1, yur dctr r ther prvider must be appinted as yur representative.

101 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 98 Yu can ask smene t act n yur behalf. If yu want t, yu can name anther persn t act fr yu as yur representative t ask fr a cverage decisin r make an appeal. There may be smene wh is already legally authrized t act as yur representative under State law. If yu want a friend, relative, yur dctr r ther prvider, r ther persn t be yur representative, call Member Services and ask fr the frm t give that persn permissin t act n yur behalf. The frm must be signed by yu and by the persn wh yu wuld like t act n yur behalf. Yu must give ur plan a cpy f the signed frm. Yu als have the right t hire a lawyer t act fr yu. Yu may cntact yur wn lawyer, r get the name f a lawyer frm yur lcal bar assciatin r ther referral service. There are als grups that will give yu free legal services if yu qualify. Hwever, yu are nt required t hire a lawyer t ask fr any kind f cverage decisin r appeal a decisin. Sectin 4.3 Which sectin f this chapter gives the details fr yur situatin? There are fur different types f situatins that invlve cverage decisins and appeals. Since each situatin has different rules and deadlines, we give the details fr each ne in a separate sectin: Sectin 5 f this chapter Sectin 6 f this chapter Sectin 7 f this chapter Sectin 8 f this chapter q q q q Hw t ask us t keep Yur medical care: Hw t ask fr a cverage decisin r make an appeal Yur Part D prescriptin drugs: Hw t ask fr a cverage decisin r make an appeal Hw t ask us t cver a lnger hspital stay if yu think the dctr is discharging yu t sn cvering certain medical services if yu think yur cverage is ending t sn (Applies t these services nly: hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services) If yu re still nt sure which sectin yu shuld be using, please call Member Services (phne numbers are n the frnt cver). Yu can als get help r infrmatin frm gvernment rganizatins such as yur State Health Insurance Assistance Prgram (Chapter 2, Sectin 3, f this bklet has the phne numbers fr this prgram). SECTION 5 Yur medical care: Hw t ask fr a cverage decisin r make an appeal? Have yu read Sectin 4 f this chapter (A guide t the basics f cverage decisins and appeals)? If nt, yu may want t read it befre yu start this sectin.

102 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 99 Sectin 5.1 This sectin tells what t d if yu have prblems getting cverage fr medical care r if yu want us t pay yu back fr ur share f the cst f yur care This sectin is abut yur benefits fr medical care and services. These are the benefits described in Chapter 4 f this bklet: Medical Benefits Chart (what is cvered and what yu pay). T keep things simple, we generally refer t medical care cverage r medical care in the rest f this sectin, instead f repeating medical care r treatment r services every time. This sectin tells what yu can d if yu are in any f the five fllwing situatins: 1. Yu are nt getting certain medical care yu want, and yu believe that this care is cvered by ur plan. 2. Our plan will nt apprve the medical care yur dctr r ther medical prvider wants t give yu, and yu believe that this care is cvered by the plan. 3. Yu have received medical care r services that yu believe shuld be cvered by the plan, but we have said we will nt pay fr this care. 4. Yu have received and paid fr medical care r services that yu believe shuld be cvered by the plan, and yu want t ask ur plan t reimburse yu fr this care. 5. Yu are being tld that cverage fr certain medical care yu have been getting will be reduced r stpped, and yu believe that reducing r stpping this care culd harm yur health. NOTE: If the cverage that will be stpped is fr hspital care, hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services, yu need t read a separate sectin f this chapter because special rules apply t these types f care. Here s what t read in thse situatins: Chapter 9, Sectin 7: Hw t ask fr a lnger hspital stay if yu think yu are being asked t leave the hspital t sn. Chapter 9, Sectin 8: Hw t ask ur plan t keep cvering certain medical services if yu think yur cverage is ending t sn. This sectin is abut three services nly: hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services. Fr all ther situatins that invlve being tld that medical care yu have been getting will be stpped, use this sectin (Sectin 5) as yur guide fr what t d. Which f these situatins are yu in? D yu want t find ut whether ur plan will cver the medical care r services yu want? Has ur plan already tld yu that we will nt cver r pay fr a medical service in the way that yu want it t be cvered r paid fr? q q q D yu want t ask ur plan t pay yu back fr medical care r services yu have already received and paid fr?

103 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 100 Yu need t ask ur plan t make a cverage decisin fr yu. G n the next sectin f this chapter, Sectin 5.2. Yu can make an appeal. (This means yu are asking us t recnsider.) Skip ahead t Sectin 5.3 f this chapter Yu can send us the bill. Skip ahead t Sectin 5.5 f this chapter. Sectin 5.2 Step-by-step: Hw t ask fr a cverage decisin (hw t ask ur plan t authrize r prvide the medical care cverage yu want) Legal Terms When a cverage decisin invlves yur medical care, it is called an rganizatin determinatin. Step 1: Yu ask ur plan t make a cverage decisin n the medical care yu are requesting. If yur health requires a quick respnse, yu shuld ask us t make a fast decisin. Legal Terms A fast decisin is called an expedited decisin. Hw t request cverage fr the medical care yu want Start by calling, writing, r faxing ur plan t make yur request fr us t authrize r prvide cverage fr the medical care yu want. Yu, r yur dctr, r yur representative can d this. Fr the details n hw t cntact us, g t Chapter 2, Sectin 1.2 and lk fr the sectin called, Hw t cntact ur plan when yu are asking fr a cverage decisin abut yur medical care. Generally we use the standard deadlines fr giving yu ur decisin When we give yu ur decisin, we will use the standard deadlines unless we have agreed t use the fast deadlines. A standard decisin means we will give yu an answer within 14 days after we receive yur request. Hwever, we can take up t 14 mre days if yu ask fr mre time, r if we need infrmatin (such as medical recrds) that may benefit yu. If we decide t take extra days t make the decisin, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. When yu file a fast cmplaint, we will give yu an answer t yur cmplaint within 24 hurs. (The prcess fr making a cmplaint is different frm the prcess fr cverage decisins and appeals. Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) If yur health requires it, ask us t give yu a fast decisin A fast decisin means we will answer within 72 hurs.

104 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 101 Hwever, we can take up t 14 mre days if we find that sme infrmatin is missing that may benefit yu, r if yu need time t get infrmatin t us fr the review. If we decide t take extra days, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) We will call yu as sn as we make the decisin. T get a fast decisin, yu must meet tw requirements: Yu can get a fast decisin nly if yu are asking fr cverage fr medical care yu have nt yet received. (Yu cannt get a fast decisin if yur request is abut payment fr medical care yu have already received.) Yu can get a fast decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin. If yur dctr tells us that yur health requires a fast decisin, we will autmatically agree t give yu a fast decisin. If yu ask fr a fast decisin n yur wn, withut yur dctr s supprt, ur plan will decide whether yur health requires that we give yu a fast decisin. If we decide that yur medical cnditin des nt meet the requirements fr a fast decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). This letter will tell yu that if yur dctr asks fr the fast decisin, we will autmatically give a fast decisin. The letter will als tell hw yu can file a fast cmplaint abut ur decisin t give yu a standard decisin instead f the fast decisin yu requested. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) Step 2: Our plan cnsiders yur request fr medical care cverage and we give yu ur answer. Deadlines fr a fast cverage decisin Generally, fr a fast decisin, we will give yu ur answer within 72 hurs. As explained abve, we can take up t 14 mre days under certain circumstances. If we decide t take extra days t make the decisin, we will tell yu in writing. If we take extra days, it is called an extended time perid. If we d nt give yu ur answer within 72 hurs (r if there is an extended time perid, by the end f that perid), yu have the right t appeal. Sectin 5.3 belw tells hw t make an appeal. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the medical care cverage we have agreed t prvide within 72 hurs after we received yur request. If we extended the time needed t make ur decisin, we will prvide the cverage by the end f that extended perid. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Deadlines fr a standard cverage decisin

105 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 102 Generally, fr a standard decisin, we will give yu ur answer within 14 days f receiving yur request. We can take up t 14 mre days ( an extended time perid ) under certain circumstances. If we decide t take extra days t make the decisin, we will tell yu in writing. If we d nt give yu ur answer within 14 days (r if there is an extended time perid, by the end f that perid), yu have the right t appeal. Sectin 5.3 belw tells hw t make an appeal. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 14 days after we received yur request. If we extended the time needed t make ur decisin, we will prvide the cverage by the end f that extended perid. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Step 3: If we say n t yur request fr cverage fr medical care, yu decide if yu want t make an appeal. If ur plan says n, yu have the right t ask us t recnsider and perhaps change this decisin by making an appeal. Making an appeal means making anther try t get the medical care cverage yu want. If yu decide t make appeal, it means yu are ging n t Level 1 f the appeals prcess (see Sectin 5.3 belw). Sectin 5.3 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a medical care cverage decisin made by ur plan) Legal Terms When yu start the appeal prcess by making an appeal, it is called the first level f appeal r a Level 1 Appeal. An appeal t the plan abut a medical care cverage decisin is called a plan recnsideratin. Step 1: Yu cntact ur plan and make yur appeal. If yur health requires a quick respnse, yu must ask fr a fast appeal. What t d T start yur appeal, yu (r yur dctr r yur representative) must cntact ur plan. Fr details n hw t reach us fr any purpse related t yur appeal, g t Chapter 2, Sectin 1.2 lk fr sectin called, Hw t cntact ur plan when yu are making an appeal abut yur medical care. If yu are asking fr a standard appeal, make yur standard appeal in writing by submitting a signed request.

106 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 103 If yu are asking fr a fast appeal, make yur appeal in writing r call us at the phne number shwn in Chapter 2, Sectin 1 (Hw t cntact ur plan when yu are making an appeal abut yur medical care). Yu must make yur appeal request within 60 calendar days frm the date n the written ntice we sent t tell yu ur answer t yur request fr a cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Yu can ask fr a cpy f the infrmatin regarding yur medical decisin and add mre infrmatin t supprt yur appeal. Yu have the right t ask us fr a cpy f the infrmatin regarding yur appeal. We are allwed t charge a fee fr cpying and sending this infrmatin t yu. If yu wish, yu and yur dctr may give us additinal infrmatin t supprt yur appeal. If yur health requires it, ask fr a fast appeal (yu can make an ral request) Legal Terms A fast appeal is als called an expedited appeal. If yu are appealing a decisin ur plan made abut cverage fr care yu have nt yet received, yu and/r yur dctr will need t decide if yu need a fast appeal. The requirements and prcedures fr getting a fast appeal are the same as thse fr getting a fast decisin. T ask fr a fast appeal, fllw the instructins fr asking fr a fast decisin. (These instructins are given earlier in this Sectin.) If yur dctr tells us that yur health requires a fast appeal, we will give yu a fast appeal. Step 2: Our plan cnsiders yur appeal and we give yu ur answer. When ur plan is reviewing yur appeal, we take anther careful lk at all f the infrmatin abut yur request fr cverage f medical care. We check t see if we were fllwing all the rules when we said n t yur request. We will gather mre infrmatin if we need it. We may cntact yu r yur dctr t get mre infrmatin. Deadlines fr a fast appeal When we are using the fast deadlines, we must give yu ur answer within 72 hurs after we receive yur appeal. We will give yu ur answer sner if yur health requires us t d s. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that may benefit yu, we can take up t 14 mre calendar days. If we decide t take extra days t make the decisin, we will tell yu in writing. If we d nt give yu an answer within 72 hurs (r by the end f the extended time perid if we tk extra days), we are required t autmatically send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we tell yu abut this rganizatin and explain what happens at Level 2 f the appeals prcess.

107 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 104 If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 72 hurs after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written denial ntice infrming yu that we have autmatically sent yur appeal t the Independent Review Organizatin fr a Level 2 Appeal. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within 30 calendar days after we receive yur appeal if yur appeal is abut cverage fr services yu have nt yet received. We will give yu ur decisin sner if yur health cnditin requires us t. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that may benefit yu, we can take up t 14 mre calendar days. If we d nt give yu an answer by the deadline abve (r by the end f the extended time perid if we tk extra days), we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent utside rganizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 30 days after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written denial ntice infrming yu that we have autmatically sent yur appeal t the Independent Review Organizatin fr a Level 2 Appeal. Step 3: If ur plan says n t part r all f yur appeal, yur case will autmatically be sent n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur appeal, ur plan is required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yur appeal is ging n t the next level f the appeals prcess, which is Level 2. Sectin 5.4 Step-by-step: Hw t make a Level 2 Appeal If ur plan says n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur first appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: The Independent Review Organizatin reviews yur appeal. The Independent Review Organizatin is an utside, independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review

108 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 105 Organizatin. Medicare versees its wrk. (Fr mre infrmatin abut this rganizatin, g t Chapter 2 and lk fr Sectin 5.) We will send the infrmatin abut yur appeal t this rganizatin. This infrmatin is called yur case file. Yu have the right t ask us fr a cpy f yur case file. We are allwed t charge yu a fee fr cpying and sending this infrmatin t yu. Yu have a right t give the Independent Review Organizatin additinal infrmatin t supprt yur appeal. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. If yu had a fast appeal at Level 1, yu will als have a fast appeal at Level 2 If yu had a fast appeal t ur plan at Level 1, yu will autmatically receive a fast appeal at Level 2. The review rganizatin must give yu an answer t yur Level 2 Appeal within 72 hurs f when it receives yur appeal. Hwever, if the Independent Review Organizatin needs t gather mre infrmatin that may benefit yu, it can take up t 14 mre calendar days. If yu had a standard appeal at Level 1, yu will als have a standard appeal at Level 2 If yu had a standard appeal t ur plan at Level 1, yu will autmatically receive a standard appeal at Level 2. The review rganizatin must give yu an answer t yur Level 2 Appeal within 30 calendar days f when it receives yur appeal. Hwever, if the Independent Review Organizatin needs t gather mre infrmatin that may benefit yu, it can take up t 14 mre calendar days. Step 2: The Independent Review Organizatin gives yu their answer. The Independent Review Organizatin will tell yu its decisin in writing and explain the reasns fr it. If the review rganizatin says yes t part r all f what yu requested, we must authrize the medical care cverage within 72 hurs r prvide the service within 14 calendar days after we receive the decisin frm the review rganizatin. If this rganizatin says n t part r all f yur appeal, it means they agree with ur plan that yur request (r part f yur request) fr cverage fr medical care shuld nt be apprved. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) The ntice yu get frm the Independent Review Organizatin will tell yu in writing if yur case meets the requirements fr cntinuing with the appeals prcess. Fr example, t cntinue and make anther appeal at Level 3, the dllar value f the medical care cverage yu are requesting must meet a certain minimum. If the dllar value f the cverage yu are requesting is t lw, yu cannt make anther appeal, which means that the decisin at Level 2 is final. Step 3: If yur case meets the requirements, yu chse whether yu want t take yur appeal further.

109 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 106 There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If yur Level 2 Appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t Level 3 and make a third appeal. The details n hw t d this are in the written ntice yu gt after yur Level 2 Appeal. The Level 3 Appeal is handled by an administrative law judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. Sectin 5.5 What if yu are asking ur plan t pay yu fr ur share f a bill yu have received fr medical care? If yu want t ask ur plan fr payment fr medical care, start by reading Chapter 7 f this bklet: Asking the plan t pay its share f a bill yu have received fr medical services r drugs Chapter 7 describes the situatins in which yu may need t ask fr reimbursement r t pay a bill yu have received frm a prvider. It als tells hw t send us the paperwrk that asks us fr payment. Asking fr reimbursement is asking fr a cverage decisin frm ur plan If yu send us the paperwrk that asks fr reimbursement, yu are asking us t make a cverage decisin (fr mre infrmatin abut cverage decisins, see Sectin 4.1 f this chapter). T make this cverage decisin, we will check t see if the medical care yu paid fr is a cvered service (see Chapter 4: Medical Benefits Chart (what is cvered and what yu pay)). We will als check t see if yu fllwed all the rules fr using yur cverage fr medical care (these rules are given in Chapter 3 f this bklet: Using the plan s cverage fr yur medical services). We will say yes r n t yur request If the medical care yu paid fr is cvered and yu fllwed all the rules, we will send yu the payment fr ur share f the cst f yur medical care within 60 calendar days after we receive yur request. Or, if yu haven t paid fr the services, we will send the payment directly t the prvider. When we send the payment, it s the same as saying yes t yur request fr a cverage decisin.) If the medical care is nt cvered, r yu did nt fllw all the rules, we will nt send payment. Instead, we will send yu a letter that says we will nt pay fr the services and the reasns why. (When we turn dwn yur request fr payment, it s the same as saying n t yur request fr a cverage decisin.) What if yu ask fr payment and we say that we will nt pay? If yu d nt agree with ur decisin t turn yu dwn, yu can make an appeal. If yu make an appeal, it means yu are asking us t change the cverage decisin we made when we turned dwn yur request fr payment. T make this appeal, fllw the prcess fr appeals that we describe in part 5.3 f this sectin. G t this part fr step-by-step instructins. When yu are fllwing these instructins, please nte: If yu make an appeal fr reimbursement, we must give yu ur answer within 60 calendar days after we receive yur appeal. (If yu are asking us t pay yu back fr medical care yu have already received and paid fr yurself, yu are nt allwed t ask fr a fast appeal.)

110 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 107 If the Independent Review Organizatin reverses ur decisin t deny payment, we must send the payment yu have requested t yu r t the prvider within 30 calendar days. If the answer t yur appeal is yes at any stage f the appeals prcess after Level 2, we must send the payment yu requested t yu r t the prvider within 60 calendar days. SECTION 6 Yur Part D prescriptin drugs: Hw t ask fr a cverage decisin r make an appeal? Have yu read Sectin 4 f this chapter (A guide t the basics f cverage decisins and appeals)? If nt, yu may want t read it befre yu start this sectin. Sectin 6.1 This sectin tells yu what t d if yu have prblems getting a Part D drug r yu want us t pay yu back fr a Part D drug Yur benefits as a member f ur plan include cverage fr many utpatient prescriptin drugs. Medicare calls these utpatient prescriptin drugs Part D drugs. Yu can get these drugs as lng as they are included in ur plan s List f Cvered Drugs (Frmulary) and they are medically necessary fr yu, as determined by yur primary care dctr r ther prvider. This sectin is abut yur Part D drugs nly. T keep things simple, we generally say drug in the rest f this sectin, instead f repeating cvered utpatient prescriptin drug r Part D drug every time. Fr details abut what we mean by Part D drugs, the List f Cvered Drugs, rules and restrictins n cverage, and cst infrmatin, see Chapter 5 (Using ur plan s cverage fr yur Part D prescriptin drugs) and Chapter 6 (What yu pay fr yur Part D prescriptin drugs). Part D cverage decisins and appeals As discussed in Sectin 4 f this chapter, a cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur drugs. Legal Terms A cverage decisin is ften called an initial determinatin r initial decisin. When the cverage decisin is abut yur Part D drugs, the initial determinatin is called a cverage determinatin. Here are examples f cverage decisins yu ask us t make abut yur Part D drugs: Yu ask us t make an exceptin, including: Asking us t cver a Part D drug that is nt n the plan s List f Cvered Drugs Asking us t waive a restrictin n the plan s cverage fr a drug (such as limits n the amunt f the drug yu can get) Asking t pay a lwer cst-sharing amunt fr a cvered nn-preferred drug

111 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 108 Yu ask us whether a drug is cvered fr yu and whether yu satisfy any applicable cverage rules. (Fr example, when yur drug is n the plan s List f Cvered Drugs but we require yu t get apprval frm us befre we will cver it fr yu.) Yu ask us t pay fr a prescriptin drug yu already bught. This is a request fr a cverage decisin abut payment. If yu disagree with a cverage decisin we have made, yu can appeal ur decisin. This sectin tells yu bth hw t ask fr cverage decisins and hw t request an appeal. Use this guide t help yu determine which part has infrmatin fr yur situatin: Which f these situatins are yu in? Request a Cverage Decisin: Make an Appeal: D yu need a drug that isn t n ur list f drugs r need us t waive a rule r restrictin n a drug we cver? D yu want us t cver a drug fr yu that is n ur list f drugs and yu d nt need us t waive a rule r restrictin n the drug yu need? D yu want t ask us t pay yu back fr a drug yu have already received and paid fr? q q q q Yu can ask us t make an exceptin. (This is a type f cverage decisin.) Yu can ask us fr a cverage decisin. Yu can ask us t pay yu back. (This is a type f cverage decisin.) Start with Sectin 6.2 f this chapter. Skip ahead t Sectin 6.4 f this chapter. Skip ahead t Sectin 6.4 f this chapter. Has ur plan already tld yu that we will nt cver r pay fr a drug in the way that yu want it t be cvered r paid fr? Yu can make an appeal. (This means yu are asking us t recnsider.) Skip ahead t Sectin 6.5 f this chapter. Sectin 6.2 What is an exceptin? If a drug is nt cvered in the way yu wuld like it t be cvered, yu can ask the plan t make an exceptin. An exceptin is a type f cverage decisin. Similar t ther types f cverage decisins, if we turn dwn yur request fr an exceptin, yu can appeal ur decisin.

112 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 109 When yu ask fr an exceptin, yur dctr r ther prescriber will need t explain the medical reasns why yu need the exceptin apprved. We will then cnsider yur request. Here are three examples f exceptins that yu r yur dctr r ther prescriber can ask us t make: 1. Cvering a Part D drug fr yu that is nt n ur plan s List f Cvered Drugs (Frmulary). (We call it the Drug List fr shrt.) Legal Terms Asking fr cverage f a drug that is nt n the Drug List is smetimes called asking fr a frmulary exceptin. If we agree t make an exceptin and cver a drug that is nt n the Drug List, yu will need t pay the cst-sharing amunt that applies t drugs in Tier 3 (nn-preferred brand). Yu cannt ask fr an exceptin t the cpayment r c-insurance amunt we require yu t pay fr the drug. Yu cannt ask fr cverage f any excluded drugs r ther nn-part D drugs which Medicare des nt cver. (Fr mre infrmatin abut excluded drugs, see Chapter 5.) 2. Remving a restrictin n the plan s cverage fr a cvered drug. There are extra rules r restrictins that apply t certain drugs n the plan s List f Cvered Drugs (fr mre infrmatin, g t Chapter 5 and lk fr Sectin 5). Legal Terms Asking fr remval f a restrictin n cverage fr a drug is smetimes called asking fr a frmulary exceptin. The extra rules and restrictins n cverage fr certain drugs include: Being required t use the generic versin f a drug instead f the brand name drug. Getting plan apprval in advance befre we will agree t cver the drug fr yu. (This is smetimes called prir authrizatin. ) Being required t try a different drug first befre we will agree t cver the drug yu are asking fr. (This is smetimes called step therapy. ) Quantity limits. Fr sme drugs, there are restrictins n the amunt f the drug yu can have. If ur plan agrees t make an exceptin and waive a restrictin fr yu, yu can ask fr an exceptin t the cpayment r c-insurance amunt we require yu t pay fr the drug. 3. Changing cverage f a drug t a lwer cst-sharing tier. Every drug n the plan s Drug List is in ne f 4 cst-sharing tiers. In general, the lwer the cst-sharing tier number, the less yu will pay as yur share f the cst f the drug. Legal Terms Asking t pay a lwer preferred price fr a cvered nnpreferred drug is smetimes called asking fr a tiering exceptin. If yur drug is in Tier 3 (nn-preferred brands) yu can ask us t cver it at the cst-sharing amunt that applies t drugs in Tier 2 (preferred brands). This wuld lwer yur share f the cst fr the drug. Yu cannt ask us t change the cst-sharing tier fr any drug in tier 4 (specialty drugs).

113 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 110 Sectin 6.3 Imprtant things t knw abut asking fr exceptins Yur dctr must tell us the medical reasns Yur dctr r ther prescriber must give us a written statement that explains the medical reasns fr requesting an exceptin. Fr a faster decisin, include this medical infrmatin frm yur dctr r ther prescriber when yu ask fr the exceptin. Typically, ur Drug List includes mre than ne drug fr treating a particular cnditin. These different pssibilities are called alternative drugs. If an alternative drug wuld be just as effective as the drug yu are requesting and wuld nt cause mre side effects r ther health prblems, we will generally nt apprve yur request fr an exceptin. Our plan can say yes r n t yur request If we apprve yur request fr an exceptin, ur apprval usually is valid until the end f the plan year. This is true as lng as yur dctr cntinues t prescribe the drug fr yu and that drug cntinues t be safe and effective fr treating yur cnditin. If we say n t yur request fr an exceptin, yu can ask fr a review f ur decisin by making an appeal. Sectin 6.5 tells hw t make an appeal if we say n. The next sectin tells yu hw t ask fr a cverage decisin, including an exceptin. Sectin 6.4 Step-by-step: Hw t ask fr a cverage decisin, including an exceptin Step 1: Yu ask ur plan t make a cverage decisin abut the drug(s) r payment yu need. If yur health requires a quick respnse, yu must ask us t make a fast decisin. Yu cannt ask fr a fast decisin if yu are asking us t pay yu back fr a drug yu already bught. What t d Request the type f cverage decisin yu want. Start by calling, writing, r faxing ur plan t make yur request. Yu, yur representative, r yur dctr (r ther prescriber) can d this. Fr the details, g t Chapter 2, Sectin 1 and lk fr the sectin called, Hw t cntact ur plan when yu are asking fr a cverage decisin abut yur Part D prescriptin drugs. Or if yu are asking us t pay yu back fr a drug, g t the sectin called, Where t send a request that asks us t pay fr ur share f the cst fr medical care r a drug yu have received. Yu r yur dctr r smene else wh is acting n yur behalf can ask fr a cverage decisin. Sectin 4 f this chapter tells hw yu can give written permissin t smene else t act as yur representative. Yu can als have a lawyer act n yur behalf. If yu want t ask ur plan t pay yu back fr a drug, start by reading Chapter 7 f this bklet: Asking the plan t pay its share f a bill yu have received fr medical services r drugs. Chapter 7 describes the situatins in which yu may need t ask fr reimbursement. It als tells hw t send us the paperwrk that asks us t pay yu back fr ur share f the cst f a drug yu have paid fr. If yu are requesting an exceptin, prvide the dctr s statement. Yur dctr r ther prescriber must give us the medical reasns fr the drug exceptin yu are requesting. (We call this the dctr s statement. ) Yur dctr r ther prescriber can fax r mail the statement t ur plan. Or yur dctr r ther prescriber can tell us n the phne and fllw up by faxing r

114 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 111 mailing the signed statement. See Sectins 6.2 and 6.3 fr mre infrmatin abut exceptin requests. If yur health requires it, ask us t give yu a fast decisin Legal Terms A fast decisin is called an expedited decisin. When we give yu ur decisin, we will use the standard deadlines unless we have agreed t use the fast deadlines. A standard decisin means we will give yu an answer within 72 hurs after we receive yur dctr s statement. A fast decisin means we will answer within 24 hurs. T get a fast decisin, yu must meet tw requirements: Yu can get a fast decisin nly if yu are asking fr a drug yu have nt yet received. (Yu cannt get a fast decisin if yu are asking us t pay yu back fr a drug yu are already bught.) Yu can get a fast decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin. If yur dctr r ther prescriber tells us that yur health requires a fast decisin, we will autmatically agree t give yu a fast decisin. If yu ask fr a fast decisin n yur wn (withut yur dctr s r ther prescriber s supprt), ur plan will decide whether yur health requires that we give yu a fast decisin. If we decide that yur medical cnditin des nt meet the requirements fr a fast decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). This letter will tell yu that if yur dctr r ther prescriber asks fr the fast decisin, we will autmatically give a fast decisin. The letter will als tell hw yu can file a cmplaint abut ur decisin t give yu a standard decisin instead f the fast decisin yu requested. It tells hw t file a fast cmplaint, which means yu wuld get ur answer t yur cmplaint within 24 hurs. (The prcess fr making a cmplaint is different frm the prcess fr cverage decisins and appeals. Fr mre infrmatin abut the prcess fr making cmplaints, see Sectin 10 f this chapter.) Step 2: Our plan cnsiders yur request and we give yu ur answer. Deadlines fr a fast cverage decisin If we are using the fast deadlines, we must give yu ur answer within 24 hurs. Generally, this means within 24 hurs after we receive yur request. If yu are requesting an exceptin, we will give yu ur answer within 24 hurs after we receive yur dctr s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent utside rganizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Appeal Level 2.

115 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 112 If ur answer is yes t part r all f what yu requested, we must prvide the cverage we have agreed t prvide within 24 hurs after we receive yur request r dctr s statement supprting yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Deadlines fr a standard cverage decisin abut a drug yu have nt yet received If we are using the standard deadlines, we must give yu ur answer within 72 hurs. Generally, this means within 72 hurs after we receive yur request. If yu are requesting an exceptin, we will give yu ur answer within 72 hurs after we receive yur dctr s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested If we apprve yur request fr cverage, we must prvide the cverage we have agreed t prvide within 72 hurs after we receive yur request r dctr s statement supprting yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Deadlines fr a standard cverage decisin abut payment fr a drug yu have already bught We must give yu ur answer within 14 calendar days after we receive yur request. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested, we are als required t make payment t yu within 14 calendar days after we receive yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Step 3: If we say n t yur cverage request, yu decide if yu want t make an appeal. If ur plan says n, yu have the right t request an appeal. Requesting an appeal means asking us t recnsider and pssibly change the decisin we made. Sectin 6.5 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a cverage decisin made by ur plan) Legal Terms When yu start the appeals prcess by making an appeal, it is called the first level f appeal r a Level 1 Appeal.

116 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 113 An appeal t the plan abut a Part D drug cverage decisin is called a plan redeterminatin. Step 1: Yu cntact ur plan and make yur Level 1 Appeal. If yur health requires a quick respnse, yu must ask fr a fast appeal. What t d T start yur appeal, yu (r yur representative r yur dctr r ther prescriber) must cntact ur plan. Fr details n hw t reach us by phne, fax, r mail fr any purpse related t yur appeal, g t Chapter 2, Sectin 1, and lk fr the sectin called, Hw t cntact ur plan when yu are making an appeal abut yur Part D prescriptin drugs. If yu are asking fr a standard appeal, make yur appeal by submitting a written request. If yu are asking fr a fast appeal, yu may make yur appeal in writing r yu may call us at the phne number shwn in Chapter 2, Sectin 1 (Hw t cntact ur plan when yu are making an appeal abut yur part D prescriptin drugs). Yu must make yur appeal request within 60 calendar days frm the date n the written ntice we sent t tell yu ur answer t yur request fr a cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Yu can ask fr a cpy f the infrmatin in yur appeal and add mre infrmatin. Yu have the right t ask us fr a cpy f the infrmatin regarding yur appeal. We are allwed t charge a fee fr cpying and sending this infrmatin t yu. If yu wish, yu and yur dctr r ther prescriber may give us additinal infrmatin t supprt yur appeal. If yur health requires it, ask fr a fast appeal Legal Terms A fast appeal is als called an expedited appeal. If yu are appealing a decisin ur plan made abut a drug yu have nt yet received, yu and yur dctr r ther prescriber will need t decide if yu need a fast appeal. The requirements fr getting a fast appeal are the same as thse fr getting a fast decisin in Sectin 6.4 f this chapter. Step 2: Our plan cnsiders yur appeal and we give yu ur answer. When ur plan is reviewing yur appeal, we take anther careful lk at all f the infrmatin abut yur cverage request. We check t see if we were fllwing all the rules when we said n t yur request. We may cntact yu r yur dctr r ther prescriber t get mre infrmatin. Deadlines fr a fast appeal If we are using the fast deadlines, we must give yu ur answer within 72 hurs after we receive yur appeal. We will give yu ur answer sner if yur health requires it.

117 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 114 If we d nt give yu an answer within 72 hurs, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an Independent Review Organizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must prvide the cverage we have agreed t prvide within 72 hurs after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n and hw t appeal ur decisin. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within 7 calendar days after we receive yur appeal. We will give yu ur decisin sner if yu have nt received the drug yet and yur health cnditin requires us t d s. If we d nt give yu a decisin within 7 calendar days, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an Independent Review Organizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested If we apprve a request fr cverage, we must prvide the cverage we have agreed t prvide as quickly as yur health requires, but n later than 7 calendar days after we receive yur appeal. If we apprve a request t pay yu back fr a drug yu already bught, we are required t send payment t yu within 30 calendar days after we receive yur appeal request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n and hw t appeal ur decisin. Step 3: If we say n t yur appeal, yu decide if yu want t cntinue with the appeals prcess and make anther appeal. If ur plan says n t yur appeal, yu then chse whether t accept this decisin r cntinue by making anther appeal. If yu decide t make anther appeal, it means yur appeal is ging n t Level 2 f the appeals prcess (see belw). Sectin 6.6 Step-by-step: Hw t make a Level 2 Appeal If ur plan says n t yur appeal, yu then chse whether t accept this decisin r cntinue by making anther appeal. If yu decide t g n t a Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur first appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE.

118 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 115 Step 1: T make a Level 2 Appeal, yu must cntact the Independent Review Organizatin and ask fr a review f yur case. If ur plan says n t yur Level 1 Appeal, the written ntice we send yu will include instructins n hw t make a Level 2 Appeal with the Independent Review Organizatin. These instructins will tell wh can make this Level 2 Appeal, what deadlines yu must fllw, and hw t reach the review rganizatin. When yu make an appeal t the Independent Review Organizatin, we will send the infrmatin we have abut yur appeal t this rganizatin. This infrmatin is called yur case file. Yu have the right t ask us fr a cpy f yur case file. We are allwed t charge yu a fee fr cpying and sending this infrmatin t yu. Yu have a right t give the Independent Review Organizatin additinal infrmatin t supprt yur appeal. Step 2: The Independent Review Organizatin des a review f yur appeal and gives yu an answer. The Independent Review Organizatin is an utside, independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t review ur decisins abut yur Part D benefits with ur plan. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. The rganizatin will tell yu its decisin in writing and explain the reasns fr it. Deadlines fr fast appeal at Level 2 If yur health requires it, ask the Independent Review Organizatin fr a fast appeal. If the review rganizatin agrees t give yu a fast appeal, the review rganizatin must give yu an answer t yur Level 2 Appeal within 72 hurs after it receives yur appeal request. If the Independent Review Organizatin says yes t part r all f what yu requested, we must prvide the drug cverage that was apprved by the review rganizatin within 24 hurs after we receive the decisin frm the review rganizatin. Deadlines fr standard appeal at Level 2 If yu have a standard appeal at Level 2, the review rganizatin must give yu an answer t yur Level 2 Appeal within 7 calendar days after it receives yur appeal. If the Independent Review Organizatin says yes t part r all f what yu requested If the Independent Review Organizatin apprves a request fr cverage, we must prvide the drug cverage that was apprved by the review rganizatin within 72 hurs after we receive the decisin frm the review rganizatin. If the Independent Review Organizatin apprves a request t pay yu back fr a drug yu already bught, we are required t send payment t yu within 30 calendar days after we receive the decisin frm the review rganizatin.

119 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 116 What if the review rganizatin says n t yur appeal? If this rganizatin says n t yur appeal, it means the rganizatin agrees with ur decisin nt t apprve yur request. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) T cntinue and make anther appeal at Level 3, the dllar value f the drug cverage yu are requesting must meet a minimum amunt. If the dllar value f the cverage yu are requesting is t lw, yu cannt make anther appeal and the decisin at Level 2 is final. The ntice yu get frm the Independent Review Organizatin will tell yu if the dllar value f the cverage yu are requesting is high enugh t cntinue with the appeals prcess. Step 3: If the dllar value f the cverage yu are requesting meets the requirement, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If yur Level 2 Appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t Level 3 and make a third appeal. If yu decide t make a third appeal, the details n hw t d this are in the written ntice yu gt after yur secnd appeal. The Level 3 Appeal is handled by an administrative law judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. SECTION 7 Hw t ask us t cver a lnger hspital stay if yu think the dctr is discharging yu t sn When yu are admitted t a hspital, yu have the right t get all f yur cvered hspital services that are necessary t diagnse and treat yur illness r injury. Fr mre infrmatin abut ur cverage fr yur hspital care, including any limitatins n this cverage, see Chapter 4 f this bklet: Medical Benefits Chart (what is cvered and what yu pay). During yur hspital stay, yur dctr and the hspital staff will be wrking with yu t prepare fr the day when yu will leave the hspital. They will als help arrange fr care yu may need after yu leave. The day yu leave the hspital is called yur discharge date. Our plan s cverage f yur hspital stay ends n this date. When yur discharge date has been decided, yur dctr r the hspital staff will let yu knw. If yu think yu are being asked t leave the hspital t sn, yu can ask fr a lnger hspital stay and yur request will be cnsidered. This sectin tells yu hw t ask. Sectin 7.1 During yur hspital stay, yu will get a written ntice frm Medicare that tells abut yur rights During yur hspital stay, yu will be given a written ntice called An Imprtant Message frm Medicare abut Yur Rights. Everyne with Medicare gets a cpy f this ntice whenever they are admitted t a hspital. Smene at the hspital is suppsed t give it t yu within tw days after yu are admitted.

120 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Read this ntice carefully and ask questins if yu dn t understand it. It tells yu abut yur rights as a hspital patient, including: Yur right t receive Medicare-cvered services during and after yur hspital stay, as rdered by yur dctr. This includes the right t knw what these services are, wh will pay fr them, and where yu can get them. Yur right t be invlved in any decisins abut yur hspital stay, and knw wh will pay fr it. Where t reprt any cncerns yu have abut quality f yur hspital care. What t d if yu think yu are being discharged frm the hspital t sn. Legal Terms The written ntice frm Medicare tells yu hw yu can make an appeal. Making an appeal is a frmal, legal way t ask fr a delay in yur discharge date s that yur hspital care will be cvered fr a lnger time. (Sectin 7.2 belw tells hw t make this appeal.) 2. Yu must sign the written ntice t shw that yu received it and understand yur rights. Yu r smene wh is acting n yur behalf must sign the ntice. (Sectin 4 f this chapter tells hw yu can give written permissin t smene else t act as yur representative.) Signing the ntice shws nly that yu have received the infrmatin abut yur rights. The ntice des nt give yur discharge date (yur dctr r hspital staff will tell yu yur discharge date). Signing the ntice des nt mean yu are agreeing n a discharge date. 3. Keep yur cpy f the signed ntice s yu will have the infrmatin abut making an appeal (r reprting a cncern abut quality f care) handy if yu need it. If yu sign the ntice mre than 2 days befre the day yu leave the hspital, yu will get anther cpy befre yu are scheduled t be discharged. T lk at a cpy f this ntice in advance, yu can call Member Services r MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can als see it nline at Sectin 7.2 Step-by-step: Hw t make a Level 1 Appeal t change yur hspital discharge date If yu want t ask fr yur hspital services t be cvered by ur plan fr a lnger time, yu will need t use the appeals prcess t make this request. Befre yu start, understand what yu need t d and what the deadlines are. Fllw the prcess. Each step in the first tw levels f the appeals prcess is explained belw. Meet the deadlines. The deadlines are imprtant. Be sure that yu understand and fllw the deadlines that apply t things yu must d. Ask fr help if yu need it. If yu have questins r need help at any time, please call Member Services (phne numbers are n the frnt cver f this bklet). Or call yur State Health Insurance

121 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 118 Assistance Prgram, a gvernment rganizatin that prvides persnalized assistance (see Sectin 2 f this chapter). During a Level 1 Appeal, the Quality Imprvement Organizatin reviews yur appeal. It checks t see if yur planned discharge date is medically apprpriate fr yu. Legal Terms When yu start the appeal prcess by making an appeal, it is called the first level f appeal r a Level 1 Appeal. Step 1: Cntact the Quality Imprvement Organizatin in yur state and ask fr a fast review f yur hspital discharge. Yu must act quickly. Legal Terms A fast review is als called an immediate review r an expedited review. What is the Quality Imprvement Organizatin? This rganizatin is a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. These experts are nt part f ur plan. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. This includes reviewing hspital discharge dates fr peple with Medicare. Hw can yu cntact this rganizatin? Act quickly: The written ntice yu received (An Imprtant Message frm Medicare) tells yu hw t reach this rganizatin. (Or find the name, address, and phne number f the Quality Imprvement Organizatin fr yur state in Chapter 2, Sectin 4, f this bklet.) T make yur appeal, yu must cntact the Quality Imprvement Organizatin befre yu leave the hspital and n later than yur planned discharge date. (Yur planned discharge date is the date that has been set fr yu t leave the hspital.) If yu meet this deadline, yu are allwed t stay in the hspital after yur discharge date withut paying fr it while yu wait t get the decisin n yur appeal frm the Quality Imprvement Organizatin. If yu d nt meet this deadline, and yu decide t stay in the hspital after yur planned discharge date, yu may have t pay all f the csts fr hspital care yu receive after yur planned discharge date. If yu miss the deadline fr cntacting the Quality Imprvement Organizatin abut yur appeal, yu can make yur appeal directly t ur plan instead. Fr details abut this ther way t make yur appeal, see Sectin 7.4. Ask fr a fast review : Yu must ask the Quality Imprvement Organizatin fr a fast review f yur discharge. Asking fr a fast review means yu are asking fr the rganizatin t use the fast deadlines fr an appeal instead f using the standard deadlines.

122 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 119 Legal Terms A fast review is als called an immediate review r an expedited review. Step 2: The Quality Imprvement Organizatin cnducts an independent review f yur case. What happens during this review? Health prfessinals at the Quality Imprvement Organizatin (we will call them the reviewers fr shrt) will ask yu (r yur representative) why yu believe cverage fr the services shuld cntinue. Yu dn t have t prepare anything in writing, but yu may d s if yu wish. The reviewers will als lk at yur medical infrmatin, talk with yur dctr, and review infrmatin that the hspital and ur plan has given t them. By nn f the day after the reviewers infrmed ur plan f yur appeal, yu will als get a written ntice that gives yur planned discharge date and explains the reasns why yur dctr, the hspital, and ur plan think it is right (medically apprpriate) fr yu t be discharged n that date. Legal Terms This written explanatin is called the Detailed Ntice f Discharge. Yu can get a sample f this ntice by calling Member Services r MEDICARE ( , 24 hurs a day, 7 days a week. TTY users shuld call ) Or yu can get see a sample ntice nline at Step 3: Within ne full day after it has all the needed infrmatin, the Quality Imprvement Organizatin will give yu its answer t yur appeal. What happens if the answer is yes? If the review rganizatin says yes t yur appeal, ur plan must keep prviding yur cvered hspital services fr as lng as these services are medically necessary. Yu will have t keep paying yur share f the csts (such as deductibles r cpayments, if these apply). In additin, there may be limitatins n yur cvered hspital services. (See Chapter 4 f this bklet). What happens if the answer is n? If the review rganizatin says n t yur appeal, they are saying that yur planned discharge date is medically apprpriate. (Saying n t yur appeal is als called turning dwn yur appeal.) If this happens, ur plan s cverage fr yur hspital services will end at nn n the day after the Quality Imprvement Organizatin gives yu its answer t yur appeal. If the review rganizatin says n t yur appeal and yu decide t stay in the hspital, then yu may have t pay the full cst f hspital care yu receive after nn n the day after the Quality Imprvement Organizatin gives yu its answer t yur appeal. Step 4: If the answer t yur Level 1 Appeal is n, yu decide if yu want t make anther appeal.

123 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 120 If the Quality Imprvement Organizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make anther appeal. Making anther appeal means yu are ging n t Level 2 f the appeals prcess. Sectin 7.3 Step-by-step: Hw t make a Level 2 Appeal t change yur hspital discharge date If the Quality Imprvement Organizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make a Level 2 Appeal. During a Level 2 Appeal, yu ask the Quality Imprvement Organizatin t take anther lk at the decisin they made n yur first appeal. Here are the steps fr Level 2 f the appeal prcess: Step 1: Yu cntact the Quality Imprvement Organizatin again and ask fr anther review. Yu must ask fr this review within 60 calendar days after the day when the Quality Imprvement Organizatin said n t yur Level 1 Appeal. Yu can ask fr this review nly if yu stayed in the hspital after the date that yur cverage fr the care ended. Step 2: The Quality Imprvement Organizatin des a secnd review f yur situatin. Reviewers at the Quality Imprvement Organizatin will take anther careful lk at all f the infrmatin related t yur appeal. Step 3: Within 14 calendar days, the Quality Imprvement Organizatin reviewers will decide n yur appeal and tell yu their decisin. If the review rganizatin says yes: Our plan must reimburse yu fr ur share f the csts f hspital care yu have received since nn n the day after the date yur first appeal was turned dwn by the Quality Imprvement Organizatin. Our plan must cntinue prviding cverage fr yur hspital care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts and cverage limitatins may apply. If the review rganizatin says n: It means they agree with the decisin they made t yur Level 1 Appeal and will nt change it. This is called uphlding the decisin. It is als called turning dwn yur appeal. The ntice yu get will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t the next level f appeal, which is handled by a judge. Step 4: If the answer is n, yu will need t decide whether yu want t take yur appeal further by ging n t Level 3. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If the review rganizatin turns dwn yur Level 2 Appeal, yu can chse whether t accept that decisin r whether t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge.

124 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 121 Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. Sectin 7.4 What if yu miss the deadline fr making yur Level 1 Appeal? Yu can appeal t ur plan instead As explained abve in Sectin 7.2, yu must act quickly t cntact the Quality Imprvement Organizatin t start yur first appeal f yur hspital discharge. ( Quickly means befre yu leave the hspital and n later than yur planned discharge date). If yu miss the deadline fr cntacting this rganizatin, there is anther way t make yur appeal. If yu use this ther way f making yur appeal, the first tw levels f appeal are different. Step-by-Step: Hw t make a Level 1 Alternate Appeal If yu miss the deadline fr cntacting the Quality Imprvement Organizatin, yu can make an appeal t ur plan, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. Legal Terms A fast review (r fast appeal ) is als called an expedited review (r expedited appeal ). Step 1: Cntact ur plan and ask fr a fast review. Fr details n hw t cntact ur plan, g t Chapter 2, Sectin 1.2 and lk fr the sectin called, Hw t cntact ur plan when yu are making an appeal abut yur medical care. Be sure t ask fr a fast review. This means yu are asking us t give yu an answer using the fast deadlines rather than the standard deadlines. Step 2: Our plan des a fast review f yur planned discharge date, checking t see if it was medically apprpriate. During this review, ur plan takes a lk at all f the infrmatin abut yur hspital stay. We check t see if yur planned discharge date was medically apprpriate. We will check t see if the decisin abut when yu shuld leave the hspital was fair and fllwed all the rules. In this situatin, we will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. Step 3: Our plan gives yu ur decisin within 72 hurs after yu ask fr a fast review ( fast appeal ). If ur plan says yes t yur fast appeal, it means we have agreed with yu that yu still need t be in the hspital after the discharge date, will t keep prviding yur cvered services fr as lng as it is medically necessary. It als means that we have agreed t reimburse yu fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. (Yu must pay yur share f the csts and there may be cverage limitatins that apply.) If ur plan says n t yur fast appeal, we are saying that yur planned discharge date was medically apprpriate. Our cverage fr yur hspital services ends as f the day we said cverage wuld end.

125 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 122 If yu stayed in the hspital after yur planned discharge date, then yu may have t pay the full cst f hspital care yu received after the planned discharge date. Step 4: If ur plan says n t yur fast appeal, yur case will autmatically be sent n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur fast appeal, ur plan is required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yu are autmatically ging n t Level 2 f the appeals prcess. Step-by-Step: Hw t make a Level 2 Alternate Appeal If ur plan says n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur fast appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: We will autmatically frward yur case t the Independent Review Organizatin. We are required t send the infrmatin fr yur Level 2 Appeal t the Independent Review Organizatin within 24 hurs f when we tell yu that we are saying n t yur first appeal. (If yu think we are nt meeting this deadline r ther deadlines, yu can make a cmplaint. The cmplaint prcess is different frm the appeal prcess. Sectin 10 f this chapter tells hw t make a cmplaint.) Step 2: The Independent Review Organizatin des a fast review f yur appeal. The reviewers give yu an answer within 72 hurs. The Independent Review Organizatin is an utside, independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review Organizatin. Medicare versees its wrk. (Fr mre infrmatin abut this rganizatin, g t Chapter 2 and lk fr Sectin 5.) Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal f yur hspital discharge. If this rganizatin says yes t yur appeal, then ur plan must reimburse yu (pay yu back) fr ur share f the csts f hspital care yu have received since the date f yur planned discharge. We must als cntinue the plan s cverage f yur hspital services fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts. If there are cverage limitatins, these culd limit hw much we wuld reimburse r hw lng we wuld cntinue t cver yur services. If this rganizatin says n t yur appeal, it means they agree with ur plan that yur planned hspital discharge date was medically apprpriate. (This is called uphlding the decisin. It is als called turning dwn yur appeal. )

126 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 123 The ntice yu get frm the Independent Review Organizatin will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a Level 3 Appeal, which is handled by a judge. Step 3: If the Independent Review Organizatin turns dwn yur appeal, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If reviewers say n t yur Level 2 Appeal, yu decide whether t accept their decisin r g n t Level 3 and make a third appeal. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. SECTION 8 Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn Sectin 8.1 This sectin is abut three services nly: Hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services This sectin is abut the fllwing types f care nly: Hme health care services yu are getting. Skilled nursing care yu are getting as a patient in a skilled nursing facility. (T learn abut requirements fr being cnsidered a skilled nursing facility, Chapter 12, Definitins f imprtant wrds.) Rehabilitatin care yu are getting as an utpatient at a Medicare-apprved Cmprehensive Outpatient Rehabilitatin Facility (CORF) services. Usually, this means yu are getting treatment fr an illness r accident, r yu are recvering frm a majr peratin. (Fr mre abut this type f facility, see Chapter 12, Definitins f imprtant wrds.) When yu are getting any f these types f care, yu have the right t keep getting yur cvered services fr that type f care fr as lng as the care is needed t diagnse and treat yur illness r injury. Fr mre infrmatin n yur cvered services, including yur share f the cst and any limitatins t cverage that may apply, see Chapter 4 f this bklet: Medical Benefits Chart (what is cvered and what yu pay). When ur plan decides it is time t stp cvering any f the three types f care fr yu, we are required t tell yu in advance. When yur cverage fr that care ends, ur plan will stp paying its share f the cst fr yur care. If yu think we are ending the cverage f yur care t sn, yu can appeal ur decisin. This sectin tells yu hw t ask. Sectin 8.2 We will tell yu in advance when yur cverage will be ending 1. Yu receive a ntice in writing. At least tw days befre ur plan is ging t stp cvering yur care, the agency r facility that is prviding yur care will give yu a letter r ntice.

127 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 124 The written ntice tells yu the date when ur plan will stp cvering the care fr yu. Legal Terms In this written ntice, we are telling yu abut a cverage decisin we have made abut when t stp cvering yur care. (Fr mre infrmatin abut cverage decisins, see Sectin 4 in this chapter.) The written ntice als tells what yu can d if yu want t ask ur plan t change this decisin abut when t end yur care, and keep cvering it fr a lnger perid f time. Legal Terms Legal Terms In telling what yu can d, the written ntice is telling hw yu can make an appeal. Making an appeal is a frmal, legal way t ask ur plan t change the cverage decisin we have made abut when t stp yur care. (Sectin 8.3 belw tells hw yu can make an appeal.) The written ntice is called the Ntice f Medicare Nn-Cverage. T get a sample cpy, call Member Services r MEDICARE ( , 24 hurs a day, 7 days a week. TTY users shuld call ). Or see a cpy nline at 2. Yu must sign the written ntice t shw that yu received it. Yu r smene wh is acting n yur behalf must sign the ntice. (Sectin 4 tells hw yu can give written permissin t smene else t act as yur representative.) Signing the ntice shws nly that yu have received the infrmatin abut when yur cverage will stp. Signing it des nt mean yu agree with the plan that it s time t stp getting the care. Sectin 8.3 Step-by-step: Hw t make a Level 1 Appeal t have ur plan cver yur care fr a lnger time If yu want t ask us t cver yur care fr a lnger perid f time, yu will need t use the appeals prcess t make this request. Befre yu start, understand what yu need t d and what the deadlines are. Fllw the prcess. Each step in the first tw levels f the appeals prcess is explained belw. Meet the deadlines. The deadlines are imprtant. Be sure that yu understand and fllw the deadlines that apply t things yu must d. There are als deadlines ur plan must fllw. (If yu think we are nt meeting ur deadlines, yu can file a cmplaint. Sectin 10 f this chapter tells yu hw t file a cmplaint.) Ask fr help if yu need it. If yu have questins r need help at any time, please call Member Services (phne numbers are n the frnt cver f this bklet). Or call yur State Health Insurance Assistance Prgram, a gvernment rganizatin that prvides persnalized assistance (see Sectin 2 f this chapter).

128 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 125 During a Level 1 Appeal, the Quality Imprvement Organizatin reviews yur appeal and decides whether t change the decisin made by ur plan. Legal Terms When yu start the appeal prcess by making an appeal, it is called the first level f appeal r Level 1 Appeal. Step 1: Make yur Level 1 Appeal: cntact the Quality Imprvement Organizatin in yur state and ask fr a review. Yu must act quickly. What is the Quality Imprvement Organizatin? This rganizatin is a grup f dctrs and ther health care experts wh are paid by the Federal gvernment. These experts are nt part f ur plan. They check n the quality f care received by peple with Medicare and review plan decisins abut when it s time t stp cvering certain kinds f medical care. Hw can yu cntact this rganizatin? The written ntice yu received tells yu hw t reach this rganizatin. (Or find the name, address, and phne number f the Quality Imprvement Organizatin fr yur state in Chapter 2, Sectin 4, f this bklet.) What shuld yu ask fr? Ask this rganizatin t d an independent review f whether it is medically apprpriate fr ur plan t end cverage fr yur medical services. Yur deadline fr cntacting this rganizatin. Yu must cntact the Quality Imprvement Organizatin t start yur appeal n later than nn f the day after yu receive the written ntice telling yu when we will stp cvering yur care. If yu miss the deadline fr cntacting the Quality Imprvement Organizatin abut yur appeal, yu can make yur appeal directly t ur plan instead. Fr details abut this ther way t make yur appeal, see Sectin 8.4. Step 2: The Quality Imprvement Organizatin cnducts an independent review f yur case. What happens during this review? Health prfessinals at the Quality Imprvement Organizatin (we will call them the reviewers fr shrt) will ask yu (r yur representative) why yu believe cverage fr the services shuld cntinue. Yu dn t have t prepare anything in writing, but yu may d s if yu wish. The review rganizatin will als lk at yur medical infrmatin, talk with yur dctr, and review infrmatin that ur plan has given t them. By the end f the day the reviewers infrmed ur plan f yur appeal, yu will als get a written ntice frm the plan that gives ur reasns fr wanting t end the plan s cverage fr yur services. Legal Terms This ntice explanatin is called the Detailed Explanatin f Nn-Cverage.

129 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 126 Step 3: Within ne full day after they have all the infrmatin they need, the reviewers will tell yu their decisin. What happens if the reviewers say yes t yur appeal? If the reviewers say yes t yur appeal, then ur plan must keep prviding yur cvered services fr as lng as it is medically necessary. Yu will have t keep paying yur share f the csts (such as deductibles r cpayments, if these apply). In additin, there may be limitatins n yur cvered services (see Chapter 4 f this bklet). What happens if the reviewers say n t yur appeal? If the reviewers say n t yur appeal, then yur cverage will end n the date we have tld yu. Our plan will stp paying its share f the csts f this care. If yu decide t keep getting the hme health care, r skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services after this date when yur cverage ends, then yu will have t pay the full cst f this care yurself. Step 4: If the answer t yur Level 1 Appeal is n, yu decide if yu want t make anther appeal. This first appeal yu make is Level 1 f the appeals prcess. If reviewers say n t yur Level 1 Appeal and yu chse t cntinue getting care after yur cverage fr the care has ended then yu can make anther appeal. Making anther appeal means yu are ging n t Level 2 f the appeals prcess. Sectin 8.4 Step-by-step: Hw t make a Level 2 Appeal t have ur plan cver yur care fr a lnger time If the Quality Imprvement Organizatin has turned dwn yur appeal and yu chse t cntinue getting care after yur cverage fr the care has ended, then yu can make a Level 2 Appeal. During a Level 2 Appeal, yu ask the Quality Imprvement Organizatin t take anther lk at the decisin they made n yur first appeal. Here are the steps fr Level 2 f the appeal prcess: Step 1: Yu cntact the Quality Imprvement Organizatin again and ask fr anther review. Yu must ask fr this review within 60 days after the day when the Quality Imprvement Organizatin said n t yur Level 1 Appeal. Yu can ask fr this review nly if yu cntinued getting care after the date that yur cverage fr the care ended. Step 2: The Quality Imprvement Organizatin des a secnd review f yur situatin. Reviewers at the Quality Imprvement Organizatin will take anther careful lk at all f the infrmatin related t yur appeal. Step 3: Within 14 days, the Quality Imprvement Organizatin reviewers will decide n yur appeal and tell yu their decisin.

130 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 127 What happens if the review rganizatin says yes t yur appeal? Our plan must reimburse yu fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. Our plan must cntinue prviding cverage fr the care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts and there may be cverage limitatins that apply. What happens if the review rganizatin says n? It means they agree with the decisin they made t yur Level 1 Appeal and will nt change it. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) The ntice yu get will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t the next level f appeal, which is handled by a judge. Step 4: If the answer is n, yu will need t decide whether yu want t take yur appeal further. There are three additinal levels f appeal after Level 2, fr a ttal f five levels f appeal. If reviewers turn dwn yur Level 2 Appeal, yu can chse whether t accept that decisin r t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. Sectin 8.5 What if yu miss the deadline fr making yur Level 1 Appeal? Yu can appeal t ur plan instead As explained abve in Sectin 9.3, yu must act quickly t cntact the Quality Imprvement Organizatin t start yur first appeal (within a day r tw, at the mst). If yu miss the deadline fr cntacting this rganizatin, there is anther way t make yur appeal. If yu use this ther way f making yur appeal, the first tw levels f appeal are different. Step-by-Step: Hw t make a Level 1 Alternate Appeal If yu miss the deadline fr cntacting the Quality Imprvement Organizatin, yu can make an appeal t ur plan, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. Here are the steps fr a Level 1 Alternate Appeal: Legal Terms A fast review (r fast appeal ) is als called an expedited review (r expedited appeal ). Step 1: Cntact ur plan and ask fr a fast review. Fr details n hw t cntact ur plan, g t Chapter 2, Sectin 1.2 and lk fr the sectin called, Hw t cntact ur plan when yu are making an appeal abut yur medical care.

131 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 128 Be sure t ask fr a fast review. This means yu are asking us t give yu an answer using the fast deadlines rather than the standard deadlines. Step 2: Our plan des a fast review f the decisin we made abut when t end cverage fr yur services. During this review, ur plan takes anther lk at all f the infrmatin abut yur case. We check t see if we were fllwing all the rules when we set the date fr ending the plan s cverage fr services yu were receiving. We will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. (Usually, if yu make an appeal t ur plan and ask fr a fast review, we are allwed t decide whether t agree t yur request and give yu a fast review. But in this situatin, the rules require us t give yu a fast respnse if yu ask fr it.) Step 3: Our plan gives yu ur decisin within 72 hurs after yu ask fr a fast review ( fast appeal ). If ur plan says yes t yur fast appeal, it means we have agreed with yu that yu need services lnger, and will keep prviding yur cvered services fr as lng as it is medically necessary. It als means that we have agreed t reimburse yu fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. (Yu must pay yur share f the csts and there may be cverage limitatins that apply.) If ur plan says n t yur fast appeal, then yur cverage will end n the date we have tld yu and ur plan will nt pay after this date. Our plan will stp paying its share f the csts f this care. If yu cntinued t get hme health care, r skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services after the date when we said yur cverage wuld yur cverage ends, then yu will have t pay the full cst f this care yurself. Step 4: If ur plan says n t yur fast appeal, yur case will autmatically g n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur fast appeal, ur plan is required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yu are autmatically ging n t Level 2 f the appeals prcess. Step-by-Step: Hw t make a Level 2 Alternate Appeal If ur plan says n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur fast appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: We will autmatically frward yur case t the Independent Review Organizatin.

132 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 129 We are required t send the infrmatin fr yur Level 2 Appeal t the Independent Review Organizatin within 24 hurs f when we tell yu that we are saying n t yur first appeal. (If yu think we are nt meeting this deadline r ther deadlines, yu can make a cmplaint. The cmplaint prcess is different frm the appeal prcess. Sectin 10 f this chapter tells hw t make a cmplaint.) Step 2: The Independent Review Organizatin des a fast review f yur appeal. The reviewers give yu an answer within 72 hurs. The Independent Review Organizatin is an utside, independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review Organizatin. Medicare versees its wrk. (Fr mre infrmatin abut this rganizatin, g t Chapter 2 and lk fr Sectin 5.) Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. If this rganizatin says yes t yur appeal, then ur plan must reimburse yu (pay yu back) fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. We must als cntinue t cver the care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts. If there are cverage limitatins, these culd limit hw much we wuld reimburse r hw lng we wuld cntinue t cver yur services. If this rganizatin says n t yur appeal, it means they agree with the decisin ur plan made t yur first appeal and will nt change it. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) The ntice yu get frm the Independent Review Organizatin will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a Level 3 Appeal. Step 3: If the Independent Review Organizatin turns dwn yur appeal, yu chse whether yu want t take yur appeal further. There are three additinal levels f appeal after Level 2, fr a ttal f five levels f appeal. If reviewers say n t yur Level 2 Appeal, yu can chse whether t accept that decisin r whether t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. SECTION 9 Taking yur appeal t Level 3 and beynd Sectin 9.1 Levels f Appeal 3, 4, and 5 fr Medical Service Appeals This sectin may be apprpriate fr yu if yu have made a Level 1 Appeal and a Level 2 Appeal, and bth f yur appeals have been turned dwn. If the dllar value f the item r medical service yu have appealed meets certain minimum levels, yu may be able t g n t additinal levels f appeal. If the dllar value is less than the minimum level, yu cannt appeal any further. If the dllar value is high enugh, the written respnse yu receive t yur Level 2 Appeal will explain wh t cntact and what t d t ask fr a Level 3 Appeal.

133 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 130 Fr mst situatins that invlve appeals, the last three levels f appeal wrk in much the same way. Here is wh handles the review f yur appeal at each f these levels. Level 3 Appeal A judge wh wrks fr the Federal gvernment will review yur appeal and give yu an answer. This judge is called an Administrative Law Judge. If the Administrative Law Judge says yes t yur appeal, the appeals prcess may r may nt be ver - We will decide whether t appeal this decisin t Level 4. Unlike a decisin at Level 2 (Independent Review Organizatin), we have the right t appeal a Level 3 decisin that is favrable t yu. If we decide nt t appeal the decisin, we must authrize r prvide yu with the service within 60 days after receiving the judge s decisin. If we decide t appeal the decisin, we will send yu a cpy f the Level 4 Appeal request with any accmpanying dcuments. We may wait fr the Level 4 Appeal decisin befre authrizing r prviding the service in dispute. If the Administrative Law Judge says n t yur appeal, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu can cntinue t the next level f the review prcess. If the administrative law judge says n t yur appeal, the ntice yu get will tell yu what t d next if yu chse t cntinue with yur appeal. Level 4 Appeal The Medicare Appeals Cuncil will review yur appeal and give yu an answer. The Medicare Appeals Cuncil wrks fr the Federal gvernment. If the answer is yes, r if the Medicare Appeals Cuncil denies ur request t review a favrable Level 3 Appeal decisin, the appeals prcess may r may nt be ver - We will decide whether t appeal this decisin t Level 5. Unlike a decisin at Level 2 (Independent Review Organizatin), we have the right t appeal a Level 4 decisin that is favrable t yu. If we decide nt t appeal the decisin, we must authrize r prvide yu with the service within 60 days after receiving the Medicare Appeals Cuncil s decisin. If we decide t appeal the decisin, we will let yu knw in writing. If the answer is n r if the Medicare Appeals Cuncil denies the review request, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu might be able t cntinue t the next level f the review prcess. It depends n yur situatin. If the Medicare Appeals Cuncil says n t yur appeal, the ntice yu get will tell yu whether the rules allw yu t g n t a Level 5 Appeal. If the rules allw yu t g n, the written ntice will als tell yu wh t cntact and what t d next if yu chse t cntinue with yur appeal.

134 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 131 Level 5 Appeal A judge at the Federal District Curt will review yur appeal. This is the last stage f the appeals prcess. This is the last step f the administrative appeals prcess. Sectin 9.2 Levels f Appeal 3, 4, and 5 fr Part D Drug Appeals This sectin may be apprpriate fr yu if yu have made a Level 1 Appeal and a Level 2 Appeal, and bth f yur appeals have been turned dwn. If the dllar value f the drug yu have appealed meets certain minimum levels, yu may be able t g n t additinal levels f appeal. If the dllar value is less than the minimum level, yu cannt appeal any further. If the dllar value is high enugh, the written respnse yu receive t yur Level 2 Appeal will explain wh t cntact and what t d t ask fr a Level 3 Appeal. Fr mst situatins that invlve appeals, the last three levels f appeal wrk in much the same way. Here is wh handles the review f yur appeal at each f these levels. Level 3 Appeal A judge wh wrks fr the Federal gvernment will review yur appeal and give yu an answer. This judge is called an Administrative Law Judge. If the answer is yes, the appeals prcess is ver. What yu asked fr in the appeal has been apprved. If the answer is n, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu can cntinue t the next level f the review prcess. If the administrative law judge says n t yur appeal, the ntice yu get will tell yu what t d next if yu chse t cntinue with yur appeal. Level 4 Appeal The Medicare Appeals Cuncil will review yur appeal and give yu an answer. The Medicare Appeals Cuncil wrks fr the Federal gvernment. If the answer is yes, the appeals prcess is ver. What yu asked fr in the appeal has been apprved. If the answer is n, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu might be able t cntinue t the next level f the review prcess. If the Medicare Appeals Cuncil says n t yur appeal r denies yur request t review the appeal, the ntice yu get will tell yu whether the rules allw yu t g n t a Level 5 Appeal. If the rules allw yu t g n, the written ntice will als tell yu wh t cntact and what t d next if yu chse t cntinue with yur appeal. Level 5 Appeal A judge at the Federal District Curt will review yur appeal.

135 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 132 This is the last step f the administrative appeals prcess. MAKING COMPLAINTS SECTION 10 Hw t make a cmplaint abut quality f care, waiting times, custmer service, r ther cncerns? If yur prblem is abut decisins related t benefits, cverage, r payment, then this sectin is nt fr yu. Instead, yu need t use the prcess fr cverage decisins and appeals. G t Sectin 4 f this chapter. Sectin 10.1 What kinds f prblems are handled by the cmplaint prcess? This sectin explains hw t use the prcess fr making cmplaints. The cmplaint prcess is used fr certain types f prblems nly. This includes prblems related t quality f care, waiting times, and the custmer service yu receive. Here are examples f the kinds f prblems handled by the cmplaint prcess.

136 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 133 If yu have any f these types f prblems, yu can make a cmplaint Quality f yur medical care Are yu unhappy with the quality f the care yu have received (including care in the hspital)? Respecting yur privacy D yu believe that smene did nt respect yur right t privacy r shared infrmatin abut yu that yu feel shuld be cnfidential? Disrespect, pr custmer service, r ther negative behavirs Has smene been rude r disrespectful t yu? Are yu unhappy with hw ur Member Services has dealt with yu? D yu feel yu are being encuraged t leave ur plan? Waiting times Are yu having truble getting an appintment, r waiting t lng t get it? Have yu been kept waiting t lng by dctrs, pharmacists, r ther health prfessinals? Or by Member Services r ther staff at ur plan? Examples include waiting t lng n the phne, in the waiting rm, in the exam rm, r when getting a prescriptin. Cleanliness Are yu unhappy with the cleanliness r cnditin f a clinic, hspital, r dctr s ffice? Infrmatin yu get frm ur plan D yu believe we have nt given yu a ntice that we are required t give? D yu think written infrmatin we have given yu is hard t understand? q The next page has mre examples f reasns yu might make a cmplaint

137 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 134 Pssible cmplaints (cntinued) These types f cmplaints are all related t the timeliness f ur actins related t cverage decisins and appeals The prcess f asking fr a cverage decisin and making appeals is explained in sectins 4-9 f this chapter. If yu are asking fr a decisin r making an appeal, yu use that prcess, nt the cmplaint prcess. Hwever, if yu have already asked fr a cverage decisin r made an appeal, and yu think that ur plan is nt respnding quickly enugh, yu can als make a cmplaint abut ur slwness. Here are examples: If yu have asked us t give yu a fast respnse fr a cverage decisin r appeal, and we have said we will nt, yu can make a cmplaint. If yu believe ur plan is nt meeting the deadlines fr giving yu a cverage decisin r an answer t an appeal yu have made, yu can make a cmplaint. When a cverage decisin we made is reviewed and ur plan is tld that we must cver r reimburse yu fr certain medical services r drugs, there are deadlines that apply. If yu think we are nt meeting these deadlines, yu can make a cmplaint. When ur plan des nt give yu a decisin n time, we are required t frward yur case t the Independent Review Organizatin. If we d nt d that within the required deadline, yu can make a cmplaint. Sectin 10.2 The frmal name fr making a cmplaint is filing a grievance Legal Terms What this sectin calls a cmplaint is als called a grievance. Anther term fr making a cmplaint is filing a grievance. Anther way t say using the prcess fr cmplaints is using the prcess fr filing a grievance. Sectin 10.3 Step-by-step: Making a cmplaint Step 1: Cntact us prmptly either by phne r in writing.

138 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 135 Usually, calling Member Services is the first step. If there is anything else yu need t d, Member Services will let yu knw , TTY: , Mnday thrugh Friday, 8 am t 8 pm. If yu d nt wish t call (r yu called and were nt satisfied), yu can put yur cmplaint in writing and send it t us. If yu d this, it means that we will use ur frmal prcedure fr answering grievances. Here s hw it wrks: A written grievance can be submitted t Medi-Pak Advantage (PFFS), Arkansas Blue Crss and Blue Shield, P.O. Bx 2181, Little Rck, Arkansas A grievance shuld be submitted with 60 days f the ccurrence. We must address yur grievance as quickly as yur case required based n yur health status, but n later than 30 days after receiving yur cmpliant. We may extend the timeframe by up t 14 days if yu ask fr the extensin, r if we justify a need fr additinal infrmatin and the delay is in yur best interest. If we deny yur grievance in whle r in part, ur written decisin will explain why we denied it, and will tell yu abut any dispute reslutin ptins yu may have. If yur health requires it, ask fr a fast grievance. We will answer yur grievance with24 hurs after we receive yur grievance. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that my benefit yu, we can take up t 14 mre days. Whether yu call r write, yu shuld cntact Member Services right away. The cmplaint must be made within 60 calendar days after yu had the prblem yu want t cmplain abut. If yu are making a cmplaint because we denied yur request fr a fast respnse t a cverage decisin r appeal, we will autmatically give yu a fast cmplaint. If yu have a fast cmplaint, it means we will give yu an answer within 24 hurs. Legal Terms What this sectin calls a fast cmplaint is als called a fast grievance. Step 2: We lk int yur cmplaint and give yu ur answer. If pssible, we will answer yu right away. If yu call us with a cmplaint, we may be able t give yu an answer n the same phne call. If yur health cnditin requires us t answer quickly, we will d that. Mst cmplaints are answered in 30 calendar days. If we need mre infrmatin and the delay is in yur best interest r if yu ask fr mre time, we can take up t 14 mre days (44 days ttal) t answer yur cmplaint. If we d nt agree with sme r all f yur cmplaint r dn t take respnsibility fr the prblem yu are cmplaining abut, we will let yu knw. Our respnse will include ur reasns fr this answer. Sectin 10.4 Yu can als make cmplaints abut quality f care t the Quality Imprvement Organizatin Yu can make yur cmplaint abut the quality f care yu received t ur plan by using the step-by-step prcess utlined abve.

139 Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 136 When yur cmplaint is abut quality f care, yu als have tw extra ptins: Yu can make yur cmplaint t the Quality Imprvement Organizatin. If yu prefer, yu can make yur cmplaint abut the quality f care yu received directly t this rganizatin (withut making the cmplaint t ur plan). T find the name, address, and phne number f the Quality Imprvement Organizatin in yur state, lk in Chapter 2, Sectin 4, f this bklet. If yu make a cmplaint t this rganizatin, we will wrk with them t reslve yur cmplaint. Or yu can make yur cmplaint t bth at the same time. If yu wish, yu can make yur cmplaint abut quality f care t ur plan and als t the Quality Imprvement Organizatin.

140 Chapter 10: Ending yur membership in the plan 137 Chapter 10. Ending yur membership in the plan SECTION 1 Intrductin 138 Sectin 1.1 This chapter fcuses n ending yur membership in ur plan 138 SECTION 2 When can yu end yur membership in ur plan? 138 Sectin 2.1 Yu can end yur membership during the Annual Enrllment Perid 138 Sectin 2.2 Sectin 2.3 Sectin 2.4 Yu can end yur membership during the Medicare Advantage Annual Disenrllment Perid, but yur chices are mre limited 139 In certain situatins, yu can end yur membership during a Special Enrllment Perid 139 Where can yu get mre infrmatin abut when yu can end yur membership? 140 SECTION 3 Hw d yu end yur membership in ur plan? 140 Sectin 3.1 Usually, yu end yur membership by enrlling in anther plan 140 SECTION 4 Until yur membership ends, yu must keep getting yur medical services and drugs thrugh ur plan 141 Sectin 4.1 Until yur membership ends, yu are still a member f ur plan 141 SECTION 5 Medi-Pak Advantage MA-PD Optin 1 (PFFS) must end yur membership in the plan in certain situatins 142 Sectin 5.1 When must we end yur membership in the plan? 142 Sectin 5.2 We cannt ask yu t leave ur plan fr any reasn related t yur health 143 Sectin 5.3 Yu have the right t make a cmplaint if we end yur membership in ur plan 143

141 Chapter 10: Ending yur membership in the plan 138 SECTION 1 Intrductin Sectin 1.1 This chapter fcuses n ending yur membership in ur plan Ending yur membership in Medi-Pak Advantage MA-PD Optin 1 (PFFS) may be vluntary (yur wn chice) r invluntary (nt yur wn chice): Yu might leave ur plan because yu have decided that yu want t leave. There are nly certain times during the year, r certain situatins, when yu may vluntarily end yur membership in the plan. Sectin 2 tells yu when yu can end yur membership in the plan. The prcess fr vluntarily ending yur membership varies depending n what type f new cverage yu are chsing. Sectin 3 tells yu hw t end yur membership in each situatin. There are als limited situatins where yu d nt chse t leave, but we are required t end yur membership. Sectin 5 tells yu abut situatins when we must end yur membership. If yu are leaving ur plan, yu must cntinue t get yur medical care and prescriptin drugs thrugh ur plan until yur membership ends. SECTION 2 When can yu end yur membership in ur plan? Yu may end yur membership in ur plan nly during certain times f the year, knwn as enrllment perids. All members have the pprtunity t leave the plan during the Annual Enrllment Perid and during the Medicare Advantage Annual Disenrllment Perid. In certain situatins, yu may als be eligible t leave the plan at ther times f the year. Sectin 2.1 Yu can end yur membership during the Annual Enrllment Perid Yu can end yur membership during the Annual Enrllment Perid (als knwn as the Annual Crdinated Electin Perid ). This is the time when yu shuld review yur health and drug cverage and make a decisin abut yur cverage fr the upcming year. When is the Annual Enrllment Perid? This happens frm Nvember 15 t December 31 in What type f plan can yu switch t during the Annual Enrllment Perid? During this time, yu can review yur health cverage and yur prescriptin drug cverage. Yu can chse t keep yur current cverage r make changes t yur cverage fr the upcming year. If yu decide t change t a new plan, yu can chse any f the fllwing types f plans: Anther Medicare Advantage plan. (Yu can chse a plan that cvers prescriptin drugs r ne that des nt cver prescriptin drugs.) Original Medicare with a separate Medicare prescriptin drug plan. r Original Medicare withut a separate Medicare prescriptin drug plan. What d yu need t d t switch plans? If yu want t switch t Original Medicare and jin a Medicare prescriptin drug plan: Simply jin the new plan. Yu will be disenrlled frm ur plan and enrlled in Original Medicare when yur new drug plan s cverage begins.

142 Chapter 10: Ending yur membership in the plan 139 If yu are planning n switching t Original Medicare withut a drug plan: Cntact Member Services fr infrmatin n hw t request disenrllment. Yu may als call MEDICARE ( ), 24 hurs a day, 7 days a week, t request disenrllment frm ur plan. TTY users shuld call When will yur membership end? Yur membership will end when yur new plan s cverage begins n January 1. Sectin 2.2 Yu can end yur membership during the Medicare Advantage Annual Disenrllment Perid, but yur chices are mre limited Yu have the pprtunity t make ne change t yur health cverage during the Medicare Advantage Annual Disenrllment Perid. When is the Medicare Advantage Annual Disenrllment Perid? This happens every year frm January 1 t February 14. What type f plan can yu switch t during the Medicare Advantage Annual Disenrllment Perid? During this time, yu can cancel yur Medicare Advantage enrllment and switch t Original Medicare. If yu chse t switch t Original Medicare, yu may als chse a separate Medicare prescriptin drug plan at the same time. When will yur membership end? Yur membership will end n the first day f the mnth after we get yur request t switch t Original Medicare. If yu als chse t enrll in a Medicare prescriptin drug plan, yur membership in the drug plan will begin at the same time. Sectin 2.3 In certain situatins, yu can end yur membership during a Special Enrllment Perid In certain situatins, members f Medi-Pak Advantage MA-PD Optin 1 (PFFS) may be eligible t end their membership at ther times f the year. This is knwn as a Special Enrllment Perid. Wh is eligible fr a Special Enrllment Perid? If any f the fllwing situatins apply t yu, yu are eligible t end yur membership during a Special Enrllment Perid. These are just examples, fr the full list yu can cntact the plan, call Medicare, r visit the Medicare website ( Usually, when yu have mved. If yu have Medicaid. If yu are eligible fr Extra Help with paying fr yur Medicare prescriptins. If yu live in a facility, such as a nursing hme. When are Special Enrllment Perids? The enrllment perids vary depending n yur situatin. What can yu d? If yu are eligible t end yur membership because f a special situatin, yu can chse t change bth yur Medicare health cverage and prescriptin drug cverage. This means yu can chse any f the fllwing types f plans:

143 Chapter 10: Ending yur membership in the plan 140 Anther Medicare Advantage plan. (Yu can chse a plan that cvers prescriptin drugs r ne that des nt cver prescriptin drugs.) Original Medicare with a separate Medicare prescriptin drug plan. r Original Medicare withut a separate Medicare prescriptin drug plan. When will yur membership end? Yur membership will usually end n the first day f the mnth after we receive yur request t change yur plan. Sectin 2.4 Where can yu get mre infrmatin abut when yu can end yur membership? If yu have any questins r wuld like mre infrmatin n when yu can end yur membership: Yu can call Member Services (phne numbers are n the cver f this bklet). Yu can find the infrmatin in the Medicare & Yu 2011 Handbk. Everyne with Medicare receives a cpy f Medicare & Yu each fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy frm the Medicare website ( Or, yu can rder a printed cpy by calling Medicare at the number belw. Yu can cntact Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call SECTION 3 Hw d yu end yur membership in ur plan? Sectin 3.1 Usually, yu end yur membership by enrlling in anther plan Usually, t end yur membership in ur plan, yu simply enrll in anther health plan during ne f the enrllment perids (see Sectin 2 fr infrmatin abut the enrllment perids). One exceptin is when yu want t switch frm ur plan t Original Medicare withut a Medicare prescriptin drug plan. In this situatin, yu must cntact Medi-Pak Advantage MA-PD Optin 1 (PFFS) Member Services and ask t be disenrlled frm ur plan. The table belw explains hw yu shuld end yur membership in ur plan.

144 Chapter 10: Ending yur membership in the plan 141 If yu wuld like t switch frm ur plan t: This is what yu shuld d: Anther Medicare Advantage plan. Enrll in the new Medicare Advantage plan. Yu will autmatically be disenrlled frm Medi-Pak Advantage MA-PD Optin 1 (PFFS) when yur new plan s cverage begins. Original Medicare with a separate Medicare prescriptin drug plan. Enrll in the new Medicare prescriptin drug plan. Yu will autmatically be disenrlled frm Medi-Pak Advantage MA-PD Optin 1 (PFFS)when yur new plan s cverage begins. Original Medicare withut a separate Medicare prescriptin drug plan. Cntact Member Services and ask t be disenrlled frm the plan (phne numbers are n the cver f this bklet). Yu can als cntact Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week, and ask t be disenrlled. TTY users shuld call Yu will be disenrlled frm Medi-Pak Advantage MA-PD Optin 1 (PFFS) when yur cverage in Original Medicare begins. SECTION 4 Until yur membership ends, yu must keep getting yur medical services and drugs thrugh ur plan Sectin 4.1 Until yur membership ends, yu are still a member f ur plan If yu leave Medi-Pak Advantage MA-PD Optin 1 (PFFS), it may take time befre yur membership ends and yur new Medicare cverage ges int effect. (See Sectin 2 fr infrmatin n when yur new cverage begins.) During this time, yu must cntinue t get yur medical care and prescriptin drugs thrugh ur plan.

145 Chapter 10: Ending yur membership in the plan 142 Yu shuld cntinue t use ur netwrk pharmacies t get yur prescriptins filled until yur membership in ur plan ends. Usually, yur prescriptin drugs are nly cvered if they are filled at a netwrk pharmacy including thrugh ur mail-rder pharmacy services. If yu are hspitalized n the day that yur membership ends, yu will usually be cvered by ur plan until yu are discharged (even if yu are discharged after yur new health cverage begins). SECTION 5 Medi-Pak Advantage MA-PD Optin 1 (PFFS) must end yur membership in the plan in certain situatins Sectin 5.1 When must we end yur membership in the plan? Medi-Pak Advantage MA-PD Optin 1 (PFFS) must end yur membership in the plan if any f the fllwing happen: If yu d nt stay cntinuusly enrlled in Medicare Part A and Part B. If yu mve ut f ur service area fr mre than 6 mnths. If yu mve r take a lng trip, yu need t call Member Services t find ut if the place yu are mving r traveling t is in ur plan s area. If yu becme incarcerated. If yu lie abut r withhld infrmatin abut ther insurance yu have that prvides prescriptin drug cverage. If yu intentinally give us incrrect infrmatin when yu are enrlling in ur plan and that infrmatin affects yur eligibility fr ur plan. If yu cntinuusly behave in a way that is disruptive and makes it difficult fr us t prvide medical care fr yu and ther members f ur plan. We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first. If yu let smene else use yur membership card t get medical care. If we end yur membership because f this reasn, Medicare may have yur case investigated by the Inspectr General. If yu d nt pay the plan premiums fr 3 mnths We must ntify yu in writing that yu have 2 mnths t pay the plan premium befre we end yur membership. Where can yu get mre infrmatin? If yu have questins r wuld like mre infrmatin n when we can end yur membership: Yu can call Member Services fr mre infrmatin (phne numbers are n the cver f this bklet).

146 Chapter 10: Ending yur membership in the plan 143 Sectin 5.2 We cannt ask yu t leave ur plan fr any reasn related t yur health What shuld yu d if this happens? If yu feel that yu are being asked t leave ur plan because f a health-related reasn, yu shuld call Medicare at MEDICARE ( ). TTY users shuld call Yu may call 24 hurs a day, 7 days a week. Sectin 5.3 Yu have the right t make a cmplaint if we end yur membership in ur plan If we end yur membership in ur plan, we must tell yu ur reasns in writing fr ending yur membership. We must als explain hw yu can make a cmplaint abut ur decisin t end yur membership. Yu can als lk in Chapter 9, Sectin 10 fr infrmatin abut hw t make a cmplaint.

147 Chapter 11: Legal ntices 144 Chapter 11. Legal ntices SECTION 1 Ntice abut gverning law 145 SECTION 2 Ntice abut nndiscriminatin 145

148 Chapter 11: Legal ntices 145 SECTION 1 Ntice abut gverning law Many laws apply t this Evidence f Cverage and sme additinal prvisins may apply because they are required by law. This may affect yur rights and respnsibilities even if the laws are nt included r explained in this dcument. The principal law that applies t this dcument is Title XVIII f the Scial Security Act and the regulatins created under the Scial Security Act by the Centers fr Medicare & Medicaid Services, r CMS. In additin, ther Federal laws may apply and, under certain circumstances, the laws f the state yu live in. SECTION 2 Ntice abut nndiscriminatin We dn t discriminate based n a persn s race, disability, religin, sex, health, ethnicity, creed, age, r natinal rigin. All rganizatins that prvide Medicare Advantage Plans, like ur plan, must bey Federal laws against discriminatin, including Title VI f the Civil Rights Act f 1964, the Rehabilitatin Act f 1973, the Age Discriminatin Act f 1975, the Americans with Disabilities Act, all ther laws that apply t rganizatins that get Federal funding, and any ther laws and rules that apply fr any ther reasn.

149 Chapter 12: Definitins f imprtant wrds 146 Chapter 12. Definitins f imprtant wrds Appeal An appeal is smething yu d if yu disagree with a decisin t deny a request fr health care services r prescriptin drugs r payment fr services r drugs yu already received. Yu may als make an appeal if yu disagree with a decisin t stp services that yu are receiving. Fr example, yu may ask fr an appeal if ur plan desn t pay fr a drug, item, r service yu think yu shuld be able t receive. Chapter 9 explains appeals, including the prcess invlved in making an appeal. Benefit Perid Fr bth ur plan and Original Medicare, a benefit perid is used t determine cverage fr inpatient stays in hspitals and skilled nursing facilities. A benefit perid begins n the first day yu g t a Medicare-cvered inpatient hspital r a skilled nursing facility. The benefit perid ends when yu haven t been an inpatient at any hspital r SNF fr 60 days in a rw. If yu g t the hspital (r SNF) after ne benefit perid has ended, a new benefit perid begins. There is n limit t the number f benefit perids yu can have. The type f care that is cvered depends n whether yu are cnsidered an inpatient fr hspital and SNF stays. Yu must be admitted t the hspital as an inpatient, nt just under bservatin. Yu are an inpatient in a SNF nly if yur care in the SNF meets certain standards fr skilled level f care. Specifically, in rder t be an inpatient in a SNF, yu must need daily skilled-nursing r skilled-rehabilitatin care, r bth. Brand Name Drug A prescriptin drug that is manufactured and sld by the pharmaceutical cmpany that riginally researched and develped the drug. Brand name drugs have the same active-ingredient frmula as the generic versin f the drug. Hwever, generic drugs are manufactured and sld by ther drug manufacturers and are generally nt available until after the patent n the brand name drug has expired. Catastrphic Cverage Stage The stage in the Part D Drug Benefit where yu pay a lw cpayment r cinsurance fr yur drugs after yu r ther qualified parties n yur behalf have spent $$4,550 in cvered drugs during the cvered year. Centers fr Medicare & Medicaid Services (CMS) The Federal agency that runs Medicare. Chapter 2 explains hw t cntact CMS. Cmprehensive Outpatient Rehabilitatin Facility (CORF) A facility that mainly prvides rehabilitatin services after an illness r injury, and prvides a variety f services including physician's services, physical therapy, scial r psychlgical services, and utpatient rehabilitatin. Cst-Sharing Cst-sharing refers t amunts that a member has t pay in additin t the plan s premium when services r drugs are received. It includes any cmbinatin f the fllwing three types f payments: (1) any deductible amunt a plan may impse befre services r drugs are cvered; (2) any fixed cpayment amunt that a plan requires when a specific service r drug is received; r (3) any cinsurance amunt, a percentage f the ttal amunt paid fr a service r drug, that a plan requires when a specific service r drug is received. Cst-Sharing Tier Every drug n the list f cvered drugs is in ne f 4 cst-sharing tiers. In general, the higher the cst-sharing tier, the higher yur cst fr the drug Cverage Determinatin A decisin abut whether a medical service r drug prescribed fr yu is cvered by the plan and the amunt, if any, yu are required t pay fr the service r prescriptin. In general, if yu bring yur prescriptin t a pharmacy and the pharmacy tells yu the prescriptin isn t cvered under yur plan,

150 Chapter 12: Definitins f imprtant wrds 147 that isn t a cverage determinatin. Yu need t call r write t yur plan t ask fr a frmal decisin abut the cverage. Cvered Drugs The term we use t mean all f the prescriptin drugs cvered by ur Plan. Cvered Services The general term we use t mean all f the health care services and supplies that are cvered by ur Plan. Creditable Prescriptin Drug Cverage Prescriptin drug cverage (fr example, frm an emplyer r unin) that is expected t cver, n average, at least as much as Medicare s standard prescriptin drug cverage. Peple wh have this kind f cverage when they becme eligible fr Medicare can generally keep that cverage withut paying a penalty, if they decide t enrll in Medicare prescriptin drug cverage later. Custdial Care Care fr persnal needs rather than medically necessary needs. Custdial care is care that can be prvided by peple wh dn t have prfessinal skills r training. This care includes help with walking, dressing, bathing, eating, preparatin f special diets, and taking medicatin. Medicare des nt cver custdial care unless it is prvided as ther care yu are getting in additin t daily skilled nursing care and/r skilled rehabilitatin services. Deductible The amunt yu must pay befre ur plan begins t pay its share f yur cvered medical services r drugs. Disenrll r Disenrllment The prcess f ending yur membership in ur plan. Disenrllment may be vluntary (yur wn chice) r invluntary (nt yur wn chice). Durable Medical Equipment Certain medical equipment that is rdered by yur dctr fr use in the hme. Examples are walkers, wheelchairs, r hspital beds. Emergency Care Cvered services that are: 1) rendered by a prvider qualified t furnish emergency services; and 2) needed t evaluate r stabilize an emergency medical cnditin. Evidence f Cverage (EOC) and Disclsure Infrmatin This dcument, alng with yur enrllment frm and any ther attachments, riders, r ther ptinal cverage selected, which explains yur cverage, what we must d, yur rights, and what yu have t d as a member f ur Plan. Exceptin A type f cverage determinatin that, if apprved, allws yu t get a drug that is nt n yur plan spnsr s frmulary (a frmulary exceptin), r get a nn-preferred drug at the preferred cst-sharing level (a tiering exceptin). Yu may als request an exceptin if yur plan spnsr requires yu t try anther drug befre receiving the drug yu are requesting, r the plan limits the quantity r dsage f the drug yu are requesting (a frmulary exceptin). Generic Drug A prescriptin drug that is apprved by the Fd and Drug Administratin (FDA) as having the same active ingredient(s) as the brand name drug. Generally, generic drugs cst less than brand name drugs. Grievance - A type f cmplaint yu make abut us r ne f ur netwrk prviders r pharmacies including a cmplaint cncerning the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes.

151 Chapter 12: Definitins f imprtant wrds 148 Hme Health Aide A hme health aide prvides services that dn t need the skills f a licensed nurse r therapist, such as help with persnal care (e.g., bathing, using the tilet, dressing, r carrying ut the prescribed exercises). Hme health aides d nt have a nursing license r prvide therapy. Initial Cverage Limit The maximum limit f cverage under the Initial Cverage Stage. Initial Cverage Stage This is the stage after yu have met yur deductible and befre yur ttal drug expenses, have reached $$2,840, including amunts yu ve paid and what ur plan has paid n yur behalf. Late Enrllment Penalty An amunt added t yur mnthly premium fr Medicare drug cverage if yu g withut creditable cverage (cverage that expects t pay, n average, at least as much as standard Medicare prescriptin drug cverage) fr a cntinuus perid f 63 days r mre. Yu pay this higher amunt as lng as yu have a Medicare drug plan. There are sme exceptins. List f Cvered Drugs (Frmulary r Drug List ) A list f cvered drugs prvided by the plan. The drugs n this list are selected by the plan with the help f dctrs and pharmacists. The list includes bth brand name and generic drugs. Lw Incme Subsidy/Extra Help A Medicare prgram t help peple with limited incme and resurces pay Medicare prescriptin drug prgram csts, such as premiums, deductibles, and cinsurance. Medicaid (r Medical Assistance) A jint Federal and State prgram that helps with medical csts fr sme peple with lw incmes and limited resurces. Medicaid prgrams vary frm state t state, but mst health care csts are cvered if yu qualify fr bth Medicare and Medicaid. See Chapter 2, Sectin 6 fr infrmatin abut hw t cntact Medicaid in yur state. Medically Necessary Drugs, services, r supplies that are prper and needed fr the diagnsis r treatment f yur medical cnditin; are used fr the diagnsis, direct care, and treatment f yur medical cnditin; meet the standards f gd medical practice in the lcal cmmunity; and are nt mainly fr yur cnvenience r that f yur dctr. Medicare The Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with certain disabilities, and peple with End-Stage Renal Disease (generally thse with permanent kidney failure wh need dialysis r a kidney transplant). Peple with Medicare can get their Medicare health cverage thrugh Original Medicare a Medicare Cst Plan, r a Medicare Advantage plan. Medicare Advantage (MA) Plan Smetimes called Medicare Part C. A plan ffered by a private cmpany that cntracts with Medicare t prvide yu with all yur Medicare Part A (Hspital) and Part B (Medical) benefits. A Medicare Advantage plan can be an HMO, PPO, a Private Fee-fr-Service (PFFS) plan, r a Medicare Medical Savings Accunt (MSA) plan. In mst cases, Medicare Advantage plans als ffer Medicare Part D (prescriptin drug cverage). These plans are called Medicare Advantage Plans with Prescriptin Drug Cverage. Everyne wh has Medicare Part A and Part B is eligible t jin any Medicare Health Plan that is ffered in their area, except peple with End-Stage Renal Disease (unless certain exceptins apply). Medicare Cst Plan Cst plan means a plan perated by a Health Maintenance Organizatin (HMO) r Cmpetitive Medical Plan (CMP) in accrdance with a cst-reimbursed cntract under sectin 1876(h) f the Act.

152 Chapter 12: Definitins f imprtant wrds 149 Medicare Cverage Gap Discunt Prgram A prgram that prvides discunts n mst cvered Part D brand name drugs t Part D enrllees wh have reached the Cverage Gap stage and wh are nt already receiving Extra Help. Discunts are based n agreements between the Federal gvernment and certain drug manufacturers. Fr this reasn, mst, but nt all, brand name drugs are discunted. Medicare Prescriptin Drug Cverage (Medicare Part D) Insurance t help pay fr utpatient prescriptin drugs, vaccines, bilgicals, and sme supplies nt cvered by Medicare Part A r Part B. Medigap (Medicare Supplement Insurance) Plicy Medicare supplement insurance sld by private insurance cmpanies t fill gaps in Original Medicare. Medigap plicies nly wrk with Original Medicare. (A Medicare Advantage plan is nt a Medigap plicy.) Member (Member f ur Plan, r Plan Member ) A persn with Medicare wh is eligible t get cvered services, wh has enrlled in ur plan and whse enrllment has been cnfirmed by the Centers fr Medicare & Medicaid Services (CMS). Member Services A department within ur plan respnsible fr answering yur questins abut yur membership, benefits, grievances, and appeals. See Chapter 2 fr infrmatin abut hw t cntact Member Services. Netwrk Pharmacy A netwrk pharmacy is a pharmacy where members f ur plan can get their prescriptin drug benefits. We call them netwrk pharmacies because they cntract with ur plan. In mst cases, yur prescriptins are cvered nly if they are filled at ne f ur netwrk pharmacies. Netwrk Prvider Prviders, such as dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities, that we have signed cntracts with t deliver cvered services t members in ur plan. These prviders have already agreed t see members f ur plan. Netwrk prviders may als be referred t as plan prviders. Organizatin Determinatin - The Medicare Advantage rganizatin has made an rganizatin determinatin when it, r ne f its prviders, makes a decisin abut whether services are cvered r hw much yu have t pay fr cvered services. Original Medicare ( Traditinal Medicare r Fee-fr-service Medicare) Original Medicare is ffered by the gvernment, and nt a private health plan like Medicare Advantage plans and prescriptin drug plans. Under Original Medicare, Medicare services are cvered by paying dctrs, hspitals, and ther health care prviders payment amunts established by Cngress. Yu can see any dctr, hspital, r ther health care prvider that accepts Medicare. Yu must pay the deductible. Medicare pays its share f the Medicare-apprved amunt, and yu pay yur share. Original Medicare has tw parts: Part A (Hspital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States. Out-f-Netwrk Pharmacy A pharmacy that desn t have a cntract with ur plan t crdinate r prvide cvered drugs t members f ur plan. As explained in this Evidence f Cverage, mst drugs yu get frm ut-f-netwrk pharmacies are nt cvered by ur plan unless certain cnditins apply. Out-f-Netwrk Prvider r Out-f-Netwrk Facility A prvider r facility with which we have nt signed a cntract r arranged t crdinate r prvide cvered services t members f ur Plan. Out-f-netwrk prviders are prviders that are nt emplyed, wned, r perated by ur plan r are nt under cntract t

153 Chapter 12: Definitins f imprtant wrds 150 deliver cvered services t yu. Using ut-f-netwrk prviders r facilities is explained in this bklet in Chapter 3. Out-f-Pcket Csts See the definitin fr cst-sharing abve. A member s cst-sharing requirement t pay fr a prtin f services r drugs received is als referred t as the member s ut-f-pcket cst requirement. Out-f-Pcket Maximum The maximum amunt that yu pay ut-f-pcket during the calendar year, usually at the time services are received, fr cvered Part A (Hspital Insurance) and Part B (Medical Insurance) services. Plan premiums and Medicare Part A and Part B premiums d nt cunt tward the ut-fpcket maximum. Part C see Medicare Advantage (MA) Plan. Part D The vluntary Medicare Prescriptin Drug Benefit Prgram. (Fr ease f reference, we will refer t the prescriptin drug benefit prgram as Part D.) Part D Drugs Drugs that can be cvered under Part D. We may r may nt ffer all Part D drugs. (See yur frmulary fr a specific list f cvered drugs.) Certain categries f drugs were specifically excluded by Cngress frm being cvered as Part D drugs. Quality Imprvement Organizatin (QIO) Grups f practicing dctrs and ther health care experts that are paid by the Federal gvernment t check and imprve the care given t Medicare patients. They must review yur cmplaints abut the quality f care given by Medicare Prviders. See Chapter 2, Sectin 4 fr infrmatin abut hw t cntact the QIO in yur state and Chapter 9 fr infrmatin abut making cmplaints t the QIO. Quantity Limits A management tl that is designed t limit the use f selected drugs fr quality, safety, r utilizatin reasns. Limits may be n the amunt f the drug that we cver per prescriptin r fr a defined perid f time. Rehabilitatin Services These services include physical therapy, speech and language therapy, and ccupatinal therapy. Service Area Service area is the gegraphic area apprved by the Centers fr Medicare & Medicaid Services (CMS) within which an eligible individual may enrll in a certain plan. Skilled Nursing Facility (SNF) Care A level f care in a SNF rdered by a dctr that must be given r supervised by licensed health care prfessinals. It may be skilled nursing care, r skilled rehabilitatin services, r bth. Skilled nursing care includes services that require the skills f a licensed nurse t perfrm r supervise. Skilled rehabilitatin services are physical therapy, speech therapy, and ccupatinal therapy. Physical therapy includes exercise t imprve the mvement and strength f an area f the bdy, and training n hw t use special equipment, such as hw t use a walker r get in and ut f a wheelchair. Speech therapy includes exercise t regain and strengthen speech and/r swallwing skills. Occupatinal therapy helps yu learn hw t perfrm usual daily activities, such as eating and dressing by yurself. Special Needs Plan A special type f Medicare Advantage plan that prvides mre fcused health care fr specific grups f peple, such as thse wh have bth Medicare and Medicaid, wh reside in a nursing hme, r wh have certain chrnic medical cnditins.

154 Chapter 12: Definitins f imprtant wrds 151 Step Therapy A utilizatin tl that requires yu t first try anther drug t treat yur medical cnditin befre we will cver the drug yur physician may have initially prescribed. Supplemental Security Incme (SSI) A mnthly benefit paid by the Scial Security Administratin t peple with limited incme and resurces wh are disabled, blind, r age 65 and lder. SSI benefits are nt the same as Scial Security benefits.