|
C and O Employees' Hospital Association
|
|
| To report any fraudulent activities click on the CMS website link below and go to the fraud and abuse section or call 1-800-medicar: http://www.cms.hhs.gov/home/medicare.asp Link to the CMS Best Available Evidence home page: http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp#TopOfPage Low Income Subsidy for Members: Click on the link below to see how CMS will pay part of your Part D premium if you qualify. CMS' payment at different levels: 100% $32.30; 75% $24.20; 50% $16.20; 25% $8.10 LIS 2011 CMS Memo 10-1-2010.pdf To report a compliant to CMS, click the link below to print a complaint form. https://www.medicare.gov/medicarecomplaintform/home.aspx
January 1 – December 31,
2012 Evidence of Coverage: Your Medicare Prescription
Drug Coverage as a Member of C and O Employees’ Hospital Association
Medicare Part D Prescription Drug Plan, an Employer/Union Medicare Part D
Prescription Drug Plan. This booklet gives you the
details about your Medicare prescription drug coverage from January 1 –
December 31, 2012. It explains how to get the prescription drugs you
need covered. This is an important legal document. Please keep it in a safe
place. This plan, C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan, is offered by C and O Employees’ Hospital Association (“COEHA”). (When this Evidence of Coverage says “we,” “us,” or “our,” it means COEHA. When it says “plan” or “our plan,” it means C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan. The COEHA has a contract with the Federal Government to provide our members with an enhanced Medicare Part D Prescription Drug Plan. Benefits, formulary, pharmacy network, premium, deductible, and/or copayments/coinsurance may change on January 1, 2013. 2012 Evidence of Coverage Table of Contents This
list of chapters and page numbers is just your starting point. For more help
in finding information you need, go to the first page of a chapter. For your
reference, we are listing the first page of each chapter.
Chapter 1.
Getting started as a member - Page 4 Tells what it means to
be in a Medicare prescription drug plan and how to use this booklet. Tells
about materials we will send you, your plan premium, your plan membership
card, and keeping your membership record up to date. Chapter 2.
Important phone numbers and resources - Page 14 Tells you how to get in
touch with our plan, C and O Employees' Hospital Association Medicare Part D
Prescription Drug Plan, and with other organizations including Medicare, the
State Health Insurance Assistance Program (SHIP), the Quality Improvement
Organization, Social Security, Medicaid (the state health insurance program
for people with low incomes), programs that help people pay for their
prescription drugs, and the Railroad Retirement Board. Chapter 3.
Using the plan’s coverage for your Part D prescription drugs -Page 24 Explains rules you need
to follow when you get your Part D drugs. Tells how to use the plan’s List
of Covered Drugs (Formulary) to find out which drugs are covered. Tells
which kinds of drugs are not
covered. Explains several kinds of restrictions that apply to coverage for
certain drugs. Explains where to get your prescriptions filled. Tells about
the plan’s programs for drug safety and managing medications. Chapter 4.
What you pay for your Part D prescription drugs - Page 41 Tells about the four
stages of drug coverage: Deductible
Stage, Initial Coverage Period, Coverage
Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you
pay for your drugs. Explains the
three cost-sharing tiers for your
Part D drugs and tells what you must pay for a drug in each cost-sharing tier.
Tells about the late enrollment penalty. Chapter 5.
Asking us to pay our share of the costs for covered drugs - Page 58 Tells when and how to
send a bill to us when you want to ask us to pay you back for our share of the
cost for your covered drugs. Chapter 6.
Your rights and responsibilities - Page 63 Explains the rights and
responsibilities you have as a member of our plan. Tells what you can do if
you think your rights are not being respected. Chapter 7.
What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) - Page 70 Tells you step-by-step what to do if you are having problems or concerns as
a member of our plan. ·
Explains how to ask for coverage decisions and make appeals if
you are having trouble getting the prescription drugs you think are covered by
our plan. This includes
asking us to make exceptions to the rules and/or extra restrictions on your
coverage. ·
Explains how to make complaints about quality of care, waiting
times, customer service, and other concerns. Chapter 8.
Ending your membership in the plan - Page 93 Tells when and how you can end your membership in the plan. Explains
situations in which our plan is required to end your membership. Chapter 9.
Legal notices - Page 100 Includes notices about governing law and about nondiscrimination. Chapter 10.
Definitions of important words - Page 106 Explains key terms used in this booklet. CHAPTER ONE, SECTION 1: INTRODUCTION You
are covered by Original Medicare for your health care coverage, and you have
chosen to get your Medicare prescription drug coverage through our plan, C and
O Employees’ Hospital Association Medicare Part D Prescription Drug Plan. There are different types of Medicare plans. C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and run by a private company. This
Evidence of Coverage booklet tells
you how to get your Medicare prescription drug coverage through our plan. This
booklet explains your rights and responsibilities, what is covered, and what
you pay as a member of the plan. This plan, C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan, is offered by C and O Employees’ Hospital Association (“ COEHA”). (When this Evidence of Coverage says “we,” “us,” or “our,” it means COEHA. When it says “plan” or “our plan,” it means C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan. The
word “coverage” and “covered drugs” refers to the prescription drug
coverage available to you as a member of C and
O Employees’ Hospital Association Medicare Part D Prescription Drug Plan.
Look through Chapter 1 of this Evidence
of Coverage to learn:
·
What is your plan’s
service area? ·
What materials will you
get from us? ·
What is your plan
premium and how can you pay it? ·
How do you keep the
information in your membership record up to date? If
you are a new member, then it’s important for you to learn how the plan
operates – what the rules are and what coverage is available to you. We
encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan’s Customer Service (contact information is on the front inside cover of this booklet).It’s
part of our contract with you This
Evidence of Coverage is part of our
contract with you about how C and O Employees’ Hospital Association Medicare
Part D Prescription Drug Plan covers
your care. Other parts of this contract include your enrollment form, the List
of Covered Drugs (Formulary), and any notices you receive from us about
changes to your coverage or conditions that affect your coverage. These
notices are sometimes called “riders” or “amendments.” The
contract is in effect for the months in which you are enrolled in C and O
Employees’ Hospital Association Medicare
Part D Prescription Drug Plan between January 1, 2012 and December 31, 2012. Medicare
must approve our plan each year Medicare
(the Centers for Medicare & Medicaid Services) must approve C and O
Employees’ Hospital Association Medicare Part D Prescription Drug Plan
each year. You can continue to get Medicare coverage as a member of our
plan only as long as we choose to continue to offer the plan for the year in
question and the Centers for Medicare & Medicaid Services renews its
approval of the plan. You are eligible for membership in
our plan as long as you are
enrolled in the original Medicare Plan, Parts A and B.
If you currently pay a premium for Medicare Part A and B, you must
continue paying your premium in order to keep your Medicare Part A and B and
remain a member of this plan and also fall in one of the following categories:
·
Former
COEHA members who discontinued membership in the COEHA, including those who
were employees of the former C&O Hospitals in Clifton Forge, VA and
Huntington, WV
·
Former employees of The Greenbrier
Hotel with Medicare coverage
When you originally signed up for Medicare, you received information about how to get Medicare Part A and Medicare Part B. Remember:
Section 2.3 Here is the plan service area for C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan Your coverage is
portable—you will never lose coverage by moving to a different state within
the United States. SECTION 3 What other materials will you get from us? Section
3.1
Your plan membership card – Use it to get all covered prescription
drugs
Some
membership cards still show COEHA/NMHC RX.
You may use these cards also. Please
carry your card with you at all times and remember to show your card when you
get covered drugs. If your plan membership card is damaged, lost, or stolen,
call COEHA Customer Service right away and we will send you a new card. You
may need to use your red, white, and blue Medicare card to get covered medical
care and services under Original Medicare. What are “network
pharmacies”? The
Informed RX
Pharmacy Directory
gives you a complete list of the
main
network pharmacies,
which
means all of the pharmacies that have agreed to fill covered prescriptions for
our plan members. Why do you need to know
about network pharmacies? You
can use the Pharmacy Directory to
find the network pharmacy you want to use. This is important because, with few exceptions, you must get your
prescriptions filled at one of the
Informed RX
network pharmacies if you want our plan to cover (help you pay for) them. If
you don’t have the Pharmacy Directory,
you can get a copy from Informed
RX Customer
Service
at 1-866-443-1095.
At any time, you can call Informed
RX Customer
Service to get
up-to-date
information about changes in the pharmacy network. You can also find this
information on their
website at
http://www.myinformedrx.com. The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered by C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan Drug List. The
Drug List also tells you if there are any rules that restrict coverage for
your drugs. The Drug List includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. To get the most complete and current information about which drugs are covered, you can visit the plan’s website at www.coeha.com or call Informed RX Customer Service at 1-866-443-1095 or check their website at http://www.myinformedrx.com. When
you use your Part D prescription
drug benefits, we will send you a summary report, upon
request, to
help you understand and keep track of payments for your Part
D prescription
drugs. This summary report is called the Explanation
of Benefits (or the “EOB”). The
Explanation of Benefits tells you the total amount you have spent on
your Part D prescription
drugs and the total amount we have paid for each of your Part
D prescription
drugs during the month. Chapter 4 (What
you pay for your Part D prescription drugs) gives more information about
the Explanation of Benefits and how
it can help you keep track of your drug coverage. SECTION 4 Your monthly premium for C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan As
a member of our plan, you pay a monthly plan premium which also includes
payment for your membership in the COEHA Supplemental Plan. For
2012, the monthly premium for
C and O Employees’ Hospital Association Medicare Part D Prescription
Drug Plan is $260.00. In
addition, you
must continue to pay your Medicare Part B premium. In some situations, your
plan premium could be less There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. Chapter 2, Section 7 tells more about these programs. If you qualify, enrolling in the program might lower your monthly plan premium. If you are already
enrolled and getting help from one of these programs, the information
about premiums in this Evidence of
Coverage may not apply to you. We will send you a separate
insert, called the “Evidence of Coverage Rider for People Who Get Extra Help
Paying for Prescription Drugs” (LIS Rider), which
tells you about your drug coverage. If you don’t have this insert,
please call COEHA Customer Service and ask for the “Evidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS
Rider). Phone numbers for COEHA Customer Service are on the inside front cover
of this booklet. In
some situations, your plan premium could be more In
some situations, your plan premium could be more than the amount listed above
in Section 4.1. These situations are described below.
Many
members are required to pay other Medicare premiums Some
plan members will be paying a premium for Medicare Part A and most plan
members will be paying a premium for Medicare Part B, in addition to paying
the monthly Part D plan premium.
Section 4.2 There are two ways you can pay your plan premium There are two
ways you can pay your plan premium: To initially set
up one of the above options, refer to page four of your COEHA Supplemental Enrollment
Form, under section entitled “PAYMENT OPTION”.
Please select Option A or B. To change your
existing method of payment, request and complete a “COEHA METHOD OF PAYMENT FORM”. If you decide to
change the way you pay your premium, it can take up to two weeks for your new
payment method to take effect. While
we are processing your request for a new payment, you are responsible for
making sure that your plan premium is paid on time. Option
A: You can pay by check You may decide to pay your plan premium directly to COEHA quarterly, semi-annually or annually. Your check should be made payable to the C and O Employees’ Hospital Association and we must receive it by the 5th of the month it is due. Your check should be mailed to the following address, or if you are local, you can drop off the check in person: C and O Employees’ Hospital Association 511 Main Street, 2nd Floor Clifton Forge, VA 24422
Option
B: Automatic dues deduction You can have your monthly plan premium automatically withdrawn from your bank account on the fifth (5th) of each month. What
to do if you are having trouble paying your plan premium Your plan premium is due in our office by the 5th of the month. If we have not received your premium by the 12th of the month, we will send you a notice telling you that your plan membership will end if we do not receive your premium payment within 90 days. If you are having trouble paying your premium on time, please contact COEHA Customer Service to see if we can direct you to programs that will help with your plan premium. If we end your membership with the plan because you did not pay your premiums, and you don’t currently have prescription drug coverage then you will not be able to receive Part D coverage elsewhere, in most cases, until the annual election period. At that time, you may either join a stand-alone prescription drug plan or a health plan that also provides drug coverage. (If you go without “creditable” drug coverage for more than 63 days, you may have to pay a premium penalty when you sign up for a Part D plan.) If we end your membership because you did not pay your
premiums, you will still have medical coverage under Original Medicare. At
the time we end your membership, you may still owe us for
premiums you have not paid. In the future, if you want to enroll again
in our plan (or another plan that we offer), you will need to pay the late
premiums before you can enroll.
If
you think we have wrongfully ended your membership, you have a right to appeal
our decision. For information about how to appeal the termination of coverage,
call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048. No.
We
are not allowed to change the amount we charge for the plan’s monthly plan
premium during the year. If the monthly plan premium changes for next year we
will tell you in the “COEHA Medicare Part D Prescription Drug Annual Notice
of Change for 2012” and the change will take effect on January 1. However, in
some cases the part of the premium that you have to pay can change during the
year. This happens if you become eligible for the Extra Help program or if you
lose your eligibility for the Extra Help program during the year. If a member
qualifies for Extra Help with their prescription drug costs, the Extra Help
program will pay part of the member’s monthly plan premium. A
member who becomes eligible for Extra Help during the year would begin to pay
less toward their monthly premium. A
member who loses their eligibility during the year will need to start paying
their full monthly premium. You can find out more about the Extra Help program
in Chapter 2, Section 7. Your membership
record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage. The pharmacists
in the plan’s network need to have correct information about you. These
network providers use your membership record to know what drugs are covered
for you. Because of this, it is very important that you help us keep your
information up to date. Let
us know about these changes: ·
Changes to your name,
your address, or your phone number ·
Changes in any other
medical or drug insurance coverage you have (such as from your employer, your
spouse’s employer, workers’ compensation, or Medicaid) ·
If you have any
liability claims, such as claims from an automobile accident ·
If you have been
admitted to a nursing home · If your designated contact person (such as a caregiver) changes If any of this
information changes, please let us know by calling COEHA Customer Service (phone
numbers are on the inside front cover of this booklet). Read
over the information we send you about any other insurance coverage you have We must
coordinate any other coverage you have with your benefits under our plan. (For
more information about how our coverage works when you have other insurance,
see Section 7 in this chapter.) From time to
time, we will send you a letter that lists any other medical or drug insurance
coverage that we know about. Please read over this information carefully. If
it is correct, you don’t need to do anything. If the information is
incorrect, or if you have other coverage that is not listed, please call COEHA
Customer Service (phone numbers are on the inside front cover of this
booklet). Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. For more information about
how we protect your personal health information, please go to Chapter 6,
Section 1.3 of this booklet. When
you have other insurance (like employer group health coverage), there are
rules set by Medicare that decide whether our plan or your other insurance
pays first. The insurance that pays first is called the “primary payer”
and pays up to the limits of its coverage. The one that pays second, called
the “secondary payer,” only pays if there are costs left uncovered by the
primary coverage. The secondary payer may not pay all of the uncovered costs. These
rules apply for employer or union group health plan coverage:
·
If
you have Medicare because of ESRD, your group health plan will pay first for
the first 30 months after you become eligible for Medicare. These
types of coverage usually pay first for services related to each type: ·
No-fault
insurance (including automobile insurance) ·
Liability
(including automobile insurance) ·
Black
lung benefits ·
Workers’
compensation Medicaid
and TRICARE never pay first for Medicare-covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call COEHA Customer Service (phone numbers are on the front inside cover of this booklet.) You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time. CHAPTER
TWO, SECTION 1: COEHA Medicare
Part D Prescription How to contact our plan’s Customer Service For assistance with claims, billing or member card questions, please call or write to COEHA Customer Service. We will be happy to help you.
How
to contact us when you are asking for a coverage decision, making an appeal or a
complaint about your Part D prescription drugs A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). An appeal is a
formal way of asking us to review and change a coverage decision we have made.
For more information on making an appeal about your Part D prescription
drugs see Chapter 7 (What to do if you have a problem or complaint [coverage decisions,
appeals, complaints]). You can make a complaint about us or one of the Informed RX pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.) For more information on making a complaint about your Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint [coverage decisions, appeals complaints]). You may call us if you have questions about our coverage
decision process or making an appeal or a complaint.
Where
to send a request asking us to pay for our share of the cost of
a drug you have received The coverage determination process includes determining requests that asks us to pay for our share of the costs of a drug that you have received. For more information on situations in which you may need to ask the plan for reimbursement or to pay a bill you have received from a provider, see Chapter 5 (Asking us to pay our share of the costs for covered drugs).
Medicare
is the Federal health insurance program for people 65 years of age or older,
some people under age 65 with disabilities, and people with End-Stage Renal
Disease (permanent kidney failure requiring dialysis or a kidney transplant). The
Federal agency in charge of Medicare is the Centers for Medicare & Medicaid
Services (sometimes called “CMS”). This agency contracts with Medicare
Prescription Drug Plans, including us.
The
State Health Insurance Assistance Program (SHIP) is a government program with
trained counselors in every state. SHIP
is independent (not connected with any insurance company or health plan). It
is a state program that gets money from the Federal government to give free
local health insurance counseling to people with Medicare. SHIP
counselors can help you with your Medicare questions or problems. They can
help you understand your Medicare rights, help you make complaints about your
medical care or treatment, and help you straighten out problems with your
Medicare bills. SHIP counselors can also help you understand your Medicare
plan choices and answer questions about switching plans.
There
is a Quality Improvement Organization for each state. The
QIO has a group of doctors and other health care professionals who are paid by
the Federal government. This organization is paid by Medicare to check on and
help improve the quality of care for people with Medicare. QIO is an
independent organization. It is not connected with our plan. You should contact QIO if you have a complaint about
the quality of care you have received. For example, you can contact QIO
if you were given the wrong medication or if you were given medications
that interact in a negative way.
The
Social Security Administration is responsible for determining eligibility and
handling enrollment for Medicare. U.S. citizens who are 65 or older, or who
have a disability or End-Stage Renal Disease and meet certain conditions, are
eligible for Medicare. If you are already getting Social Security checks,
enrollment into Medicare is automatic. If you are not getting Social Security
checks, you have to enroll in Medicare. Social Security handles the enrollment
process for Medicare. To apply for Medicare, you can call Social Security or
visit your local Social Security office.
Medicaid
is a joint Federal and state government program that helps with medical costs
for certain people with limited incomes and resources. Some people with
Medicare are also eligible for Medicaid. In addition, there are programs offered through Medicaid
that help people with Medicare pay their Medicare costs, such as their
Medicare premiums. These programs help people with limited income
and resources save money each year: ·
Qualified Medicare
Beneficiary (QMB): Helps pay Medicare
Part A and Part B premiums, and other cost sharing (like deductibles,
coinsurance, and copayments). ·
Specified Low-Income
Medicare Beneficiary (SLMB) and Qualifying Individual (QI): Helps pay Part B
premiums. ·
Qualified Disabled
& Working Individuals (QDWI): Helps pay Part A premiums. To
find out more about Medicaid and its programs, contact
Medicare’s
“Extra Help” Program Medicare
provides “Extra Help” to pay prescription drug costs for people who have
limited income and resources. Resources include your savings and stocks, but
not your home or car. If you qualify, you get help paying for any Medicare
drug plan’s monthly premium, yearly deductible and prescription copayments.
This Extra Help also counts toward your out-of-pocket costs. People with limited income and resources may qualify for Extra Help. Some
people automatically qualify for Extra Help and don’t need to apply.
Medicare mails a letter to people who automatically qualify for Extra Help. You
may be able to get Extra Help to pay for your prescription drug premiums and
costs. To see if you qualify for getting Extra Help, call:
If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper co-payment level, or, if you already have the evidence, to provide this evidence to us. · We will assist our member upon request to get Extra Help in obtaining the best available evidence by contacting their pharmacist, patient advocate, Social Security or Medicaid office. · When we receive the evidence showing your copayment level, we will have Informed RX update their system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, Informed RX will reimburse you. They will either forward a check to you in the amount of your overpayment or they will offset future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, Informed RX may make the payment directly to the pharmacy. If a state paid on your behalf, Informed RX may make payment directly to the state. Please contact COEHA Customer Service if you have questions. Medicare Coverage Gap Discount Program The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enrollees who have reached the coverage gap and are not already receiving “Extra Help.” A 50% discount on the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) is available for those brand name drugs from manufacturers that have agreed to pay the discount. If you reach the coverage gap, Informed RX will automatically apply the discount when your pharmacy bills you for your prescription and your Explanation of Benefits (EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. You also
receive some coverage for generic
drugs. If you reach the coverage gap, the plan pays 14% of
the price for generic drugs and you pay the remaining 86% of the price. The
coverage for generic drugs works differently than the 50% discount for brand
name drugs. For generic drugs, the amount paid by the plan (14%) does not
count toward your out-of-pocket costs. Only the amount you pay counts and
moves you through the coverage gap. Also, the dispensing fee is included as
part of the cost of the drug. If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact COEHA Customer Service (phone numbers are on the front inside cover of this booklet). What if you have coverage from a State Pharmaceutical Assistance
Program (SPAP)? If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than Extra Help), you still get the 50% discount on covered brand name drugs. The 50% discount is applied to the price of the drug before any SPAP or other coverage. What if you get Extra Help from Medicare to help pay your
prescription drug costs? Can you get the discounts? No.
If you get Extra Help, you already get coverage for your prescription drug
costs during the coverage gap. What
if you don’t get a discount, and you think you should have? If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should request from us an Explanation of Benefits (EOB) notice. If the discount doesn’t appear on your Explanation of Benefits, you should contact us to make sure that your prescription records are correct and up-to-date. If we don’t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this Chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. State Pharmaceutical
Assistance Programs Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules to provide drug coverage to its members. These programs provide
limited income and medically needy seniors and individuals with disabilities
financial help for prescription drugs.
The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation’s railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board, contact the agency.
If you have other prescription drug coverage through your (or your spouse’s) employer or retiree group, please contact that group’s benefits administrator. The benefits administrator can help you determine how your current prescription drug coverage will work with our plan.
Introduction Did you know
there are programs to help people pay for
their drugs? There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section7.
Are you currently getting help
to pay for
your drugs? If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider), that tells you about your drug coverage. If you receive this insert, please call COEHA Customer Service and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Phone numbers for COEHA Customer Service are on the inside front cover. Section 1.1 This chapter describes your coverage for Part D drugs This chapter explains rules for using your coverage for Part D drugs.
The next chapter tells what you pay for Part D drugs (Chapter 4, What
you pay for your Part D prescription drugs). In addition to your coverage for Part D drugs through our plan, Original
Medicare (Medicare Part A and Part B) also
covers some drugs: · Medicare Part A covers drugs you are given during Medicare-covered stays in the hospital or in a skilled nursing facility.
The two examples of drugs described above are covered by Original
Medicare. (To find out more about this coverage, see your Medicare & You Handbook.) Your Part D prescription drugs are
covered under our plan. This
chapter explains rules for using your coverage for Part D drugs under our
plan. The next chapter tells what you pay for Part D drugs (Chapter 4, What
you pay for your Part D prescription drugs). Section 1.2 Basic rules for the plan’s Part D drug coverage The plan will
generally cover your drugs as long as you follow these basic rules:
Section 2.1 To have your prescription covered, use a network pharmacy In most cases, your prescriptions are covered only if they are filled at Informed RX network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with
Informed RX to provide your covered prescription drugs. The term “covered
drugs” means all of the Part D prescription drugs that are covered on the
plan’s Drug List. Section 2.2 Finding network pharmacies How do you find a network
pharmacy in your area? To find a network pharmacy, you can look in your Pharmacy Directory, visit the Informed RX, http://myinformedrx.com, call Informed RX Customer Service at 1-866-443-1095 or visit our website www.coeha.com, or call COEHA Customer Service (phone numbers are on the front inside cover of this booklet). Choose whatever is easiest for you. You may go to any of the Informed RX network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask to have a new prescription written by a doctor or to have your prescription transferred to your new network pharmacy. What
if the pharmacy you have been using leaves the network? If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from Informed RX Customer Service or use the Pharmacy Directory. What if you need a
specialized pharmacy? Sometimes prescriptions must be filled at a specialized pharmacy. The Informed RX network does have specialized pharmacies. Specialized pharmacies include:
To locate a specialized pharmacy, look in your Pharmacy Directory or call Informed RX Customer Service. Section
2.3
Using
the plan’s mail-order services Our plan’s mail-order service through Informed RX is mainly used for 90-day fills. To get order forms and information about filling your prescriptions by mail, please call Informed RX Customer Service. If you use a mail-order pharmacy not in the Informed RX network, your prescription will not be covered. Usually a mail-order pharmacy order will get to you in no more than 14 days. You should call Informed RX or COEHA Customer Service if your mail order is delayed. Section 2.4 How can you get a long-term supply of drugs? When you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two ways to get a long-term supply of “mail-order” drugs on our plan’s Drug List. (Mail-order drugs are usually drugs that you take on a regular basis, for a chronic or long-term medical condition.)
Section
2.5
When
can you use a pharmacy that is not in the Informed RX network? Your
prescription may be covered in certain situations We cover drugs filled at an out-of-network pharmacy only under emergency circumstances when you are not able to use a network pharmacy. In these situations, please check first with Informed RX Customer Service to see if there is a network pharmacy nearby. How
do you ask for reimbursement from the plan? If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to pay you back.) Section 3.1 The “Drug List” tells which Part D drugs are covered The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter, Section 1.1 explains about Part D drugs). We will generally cover a drug on the plan’s Drug List as long as you follow the other coverage rules explained in this chapter and use of the drug meets the following criteria of a “medically accepted indication”. A “medically accepted indication” is a use of the drug that is either:
The Drug List includes
both brand name and generic drugs A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs. What is not
on the Drug List? The plan does not cover all prescription drugs. · In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more about this, see Section 7.1 in this chapter). · In other cases, we have decided not to include a particular drug on our Drug List. Section
3.2
There
are three “cost-sharing tiers” for drugs on the Drug List Every drug on the plan’s Drug List is in one of three cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug: · Tier is for generic medications · Tier 2 is for preferred brand medication · Tier 3 is for “non-preferred” medications. These medications have a less expensive, clinical alternative medication available on Tier 2 Tier One is the least expensive and Tier Three is the most expensive. To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List. The amount you
pay for drugs in each cost-sharing tier is shown in Chapter 4 (What
you pay for your Part D prescription drugs). Section
3.3
How
can you find out if a specific drug is on the Drug List? You have three ways to find out: 1. Visit the plan’s website www.coeha.com. The Drug List on the website is always the most current. 2. Call Informed RX Customer Service to find out if a particular drug is on the plan’s Drug List or to ask for a copy of the list. Call 1-866-443-1095. 3. Visit the Informed RX website, http://www.myinformedrx.com . Section 4.1 Why do some drugs have restrictions? For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. In
general, our rules encourage you to get a drug that works for your medical condition and is safe
and effective.
Whenever a safe, lower-cost drug will work medically just as well as a
higher-cost drug, the plan’s rules are designed to encourage you and your provider
to use that
lower-cost option. We also need to comply with Medicare’s rules and
regulations for drug coverage and cost sharing. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the formal appeals process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.) Section 4.2 What kinds of restrictions? Our
plan uses different types of restrictions to help our members use drugs in the
most effective ways. The sections below tell you more about the types of
restrictions we use for certain drugs. Getting
plan approval in advance For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. Quantity
limits For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. Section 4.3 Do any of these restrictions apply to your drugs? The plan’s Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call Informed RX Customer Service, check their website at http://myinformedrx.com, or check our website at www.coeha.com. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact COEHA Customer Service to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the formal appeals process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.) Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered Suppose there is a prescription drug you are currently taking, or one that you and your provider think you should be taking. We hope that your drug coverage will work well for you, but it’s possible that you might have a problem. For example: ·
What
if the drug you want to take is not covered by the plan?
For example, the drug might not be covered at all. Maybe a generic version of
the drug is covered but the brand name version you want to take is not
covered. ·
What
if the drug is covered, but there are extra rules or restrictions on coverage
for that drug?
As explained in Section 4, some of the drugs covered by the plan have
extra rules to restrict their use. For example, there might be limits on what
amount of the drug (number of pills, etc.) is
covered during a particular time period. In some cases, you may want us to
waive the restriction for you. For example, you
may want us to cover more of a drug (number of
pills, etc.) than we normally will cover. ·
What
if the drug is covered, but it is in a cost-sharing tier that makes your cost
sharing more expensive than you think it should be? The plan puts each covered drug into one of three different
cost-sharing tiers. How much you pay for your prescription depends in part on
which cost-sharing tier your drug is in. There
are things you can do if your drug is not covered in the way that you’d like
it to be covered. Your
options depend on what type of problem you have: ·
If
your drug is not on the Drug List or if your drug is restricted, go to Section
5.2 to learn what you can do. ·
If
your drug is in a cost-sharing tier that makes your cost more expensive than
you think it should be, go to Section 5.3 to learn what you can do. Section
5.2
What
can you do if your drug is not on the Drug List or if the drug is restricted
in some way? If
your drug is not on the Drug List or is restricted, here are things you can
do: ·
You
may be able to get a temporary supply of the drug (only members in certain
situations can get a temporary supply). This will give you and your provider
time to change to another drug or to file a request to have the drug covered. ·
You
can change to another drug. ·
You
can request an exception and ask the plan to cover the drug or remove
restrictions from the drug. You
may be able to get a temporary supply Under
certain circumstances, the plan can
offer a temporary supply of a drug to you when your drug is not on the Drug
List or when it is restricted in some way. Doing this gives you time to talk
with your provider about the change in coverage and figure out what to do. To be eligible for a temporary supply, you must meet the two requirements below: 1.
The change to your drug coverage must be one of the following types of
changes: ·
The drug you have
been taking is no longer on the
plan’s Drug List. ·
-- or -- the drug you
have been taking is now restricted in
some way (Section 4 in this chapter tells about restrictions). 2.
You must be in one of the situations described below:
We
will cover a temporary supply of your drug one
time only during the first 90 days of the
calendar year. This temporary supply will be for a maximum of 30 days, or
less if your prescription is written for fewer days. The prescription must be
filled at an Informed RX network pharmacy.
We
will cover a temporary supply of your drug one
time only during the first 90 days of your membership in the plan. This
temporary supply will be for a maximum of 30 days, or less if your
prescription is written for fewer days. The prescription must be filled at an
Informed RX network pharmacy.
We
will cover a temporary supply of
your drug during the first 90 days of your membership in the plan. The first
supply will be for a maximum of 31 days, or less if your prescription is
written for fewer days. If needed, we will cover additional refills during
your first 90 days in the plan.
We
will cover one 31-day supply, or less if your prescription is written for
fewer days. This is in addition to the above long-term care transition supply.
We
will cover one 31-day supply, or less if your prescription is written for
fewer days. This is an addition to
the above long-term transition supply. To
ask for a temporary supply, call Informed RX Customer Service at
1-866-443-1095. During
the time when you are getting a temporary supply of a drug, you should talk
with your provider to decide what to do when your temporary supply runs out.
You can either switch to a different drug covered by the plan or ask the plan
to make an exception for you and cover your current drug. The sections below
tell you more about these options. You can change to another drug Start by talking with your provider. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Informed RX Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. You
can ask for an exception You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List. You can ask the plan to make an exception and cover the drug without restrictions. If
you are a current member and a drug you are taking will be removed from the
formulary or restricted in some way for next year, we will allow you to
request a formulary exception in advance for next year. We will tell you about
any change in the coverage for your drug for the following year. You can then
ask us to make an exception and cover the drug in the way you would like it to
be covered for the following year. We will give you an answer to your request
for an exception before the change takes effect. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? If your drug is in a cost-sharing tier you think is too high, here are things you can do: You
can change to another drug If
your drug is in a cost-sharing tier you think is too high, start by talking
with your provider. Perhaps there is a different drug in a lower cost-sharing
tier that might work just as well for you. You can call Informed RX Customer
Service to ask for a list of covered drugs that treat the same medical
condition. This list can help your provider find a covered drug that might
work for you. You
can ask for an exception For
drugs in the three tiers, you and your provider can ask the plan to make an
exception in the cost-sharing tier for the drug so that you pay less for it.
If your provider says that you have medical reasons that justify asking us for
an exception, your provider can help you request an exception to the rule. If
you and your provider want to ask for an exception, Chapter 7, Section 5.4
tells what to do. It explains the
procedures and deadlines that have been set by Medicare to make sure your
request is handled promptly and fairly. Drugs in some of our cost-sharing tiers are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs in tiers one and two Section 6.1 The Drug List can change during the year Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might: · Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. We might remove a drug from the list because it has been found to be ineffective. ·
Move
a drug to a higher or lower cost-sharing tier. · Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 4 in this chapter). ·
Replace a brand name drug
with a generic drug. In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. Section
6.2
What
happens if coverage changes for a drug you are taking? How
will you find out if your drug’s coverage has been changed? If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once
in a while, a drug is suddenly recalled
because it’s been found to be unsafe or for other reasons. If this happens,
the plan will immediately remove the drug from the Drug List. We will let you
know of this change right away. Your provider will also know about this
change, and can work with you to find another drug for your condition. Do
changes to your drug coverage affect you right away? If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan: ·
If we move your drug into a higher
cost-sharing tier. · If we put a new restriction on your use of the drug. ·
If we remove your drug from the Drug List, but not because of a
sudden recall or because a new generic drug has replaced it. If
any of these changes happens for a drug you are taking, then the change
won’t affect your use or what you pay as your share of the cost until
January 1 of the next year. Until that date, you probably won’t see any
increase in your payments or any added restriction to your use of the drug.
However, on January 1 of the next year, the changes will affect you. In some cases, you will be affected by the coverage change before January 1: ·
If a brand name drug you
are taking is replaced by a new generic drug, the plan must give you at
least 60 days’ notice or give you a 60-day refill of your brand name drug at
a network pharmacy. o
During this 60-day period, you should be working with your
provider to switch to the generic or to a different drug that we cover. o
You and your provider can ask the plan to make an exception and
continue to cover the brand name drug for you. For information on how to ask
for an exception, see Chapter 7 (What to do if you have a problem or complaint [coverage
decisions, appeals, complaints]).
· If a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. o Your provider will also know about this change, and can work with you to find another drug for your condition. Section 7.1 Types of drugs we do not cover This section tells you what kinds of prescription drugs are “excluded.” This means Medicare does not pay for these drugs. If
you get drugs that are excluded, you must pay for them yourself.
We won’t pay for the drugs that are listed in this section (except
for certain excluded drugs covered under our enhanced drug
coverage). The only exception: If the
requested drug is found upon appeal to be a drug that is not excluded under
Part D and we should have paid for or covered it because of your specific
situation. (For information about appealing a decision we have made to
not cover a drug, go to Chapter 7, Section 5.5 in this booklet.) Here are three general rules about drugs that Medicare drug plans will not cover under Part D: ·
Our plan’s Part D drug coverage cannot
cover a drug that would be covered under Medicare Part A or Part B. ·
Our plan cannot cover a drug purchased
outside the United States and its territories. · Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration. o Generally, coverage for “off-label use” is allowed only when the use is supported by certain reference books. These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor. If the use is not supported by any of these reference books, then our plan cannot cover its “off-label use.” Also, by law, these categories of drugs are not covered by Medicare drug plans: (Our plan covers certain drugs listed below through our enhanced drug coverage, for which you may be charged an additional premium. More information is provided below.) ·
Non-prescription drugs (also called
over-the-counter drugs) with
the exception of Prilosec OTC, Claritin OTC, Zyrtec OTC and Allegra OTC · Drugs when used to promote fertility · Drugs when used for the relief of cough or cold symptoms · Drugs when used for cosmetic purposes or to promote hair growth · Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations · Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject · Drugs when used for treatment of anorexia, weight loss, or weight gain · Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale · Barbiturates and Benzodiazepines We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage). As listed above under non-prescription drugs, we do cover the following over-the-counter drugs. There is no copayment due by you for these drugs, therefore, these drugs do not count towards qualifying you for the Catastrophic Cover Stage. (The Catastrophic Coverage Stage is described in Chapter 4, Section 7 of this booklet.) · Prilosec OTC · Claritin OTC · Zyrtec OTC · Allegra OTC In addition, if you are receiving Extra Help from Medicare to pay for your prescriptions, the Extra Help program will not pay for the drugs not normally covered. (Please refer to your formulary or call Informed RX Customer Service for more information.) However, if you have drug coverage through Medicaid, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.) Section 8.1 Show your membership card To fill your prescription, show your Informed RX card at the network pharmacy you choose. When you show your plan membership card, the network pharmacy will automatically bill the plan through Informed RX for our share of your covered prescription drug cost. You will need to pay the pharmacy your share of the cost when you pick up your prescription. Section 8.2 What if you don’t have your membership card with you? If you don’t have your Informed RX with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information. If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 5, Section 2.1 for information about how to ask the plan for reimbursement.) Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare? If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage. If you are admitted to a skilled nursing facility for a stay covered by Original Medicare, Medicare Part A will generally cover your prescription drugs during all or part of your stay. If you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage. Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a special enrollment period. During this time period, you can switch plans or change your coverage at any time. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan and join a different Medicare plan.) Section 9.2 What if you’re a resident in a long-term care facility? Usually, a long-term care facility (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part of our network. Check your Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of our network. If it isn’t, or if you need more information, please contact Informed RX Customer Service. What
if you are a resident in a long-term care facility and become a new member of
the plan? If
you need a drug that is not on our Drug List or is restricted in some way, the
plan will cover a temporary supply
of your drug during the first 90 days of your membership. The
first supply will be for a maximum of a 31-day supply or less if your
prescription is written for fewer days.
If needed, we will cover additional refills during your first 90 days in the
plan. If
you have been a member of the plan for more than 90 days and need a drug that
is not on our Drug List or if the plan has any restriction on the drug’s
coverage, we will cover one
31-day supply, or less if your prescription is written for fewer days.
During
the time when you are getting a temporary supply of a drug, you should talk
with your provider to decide what to do when your temporary supply runs out.
Perhaps there is a different drug covered by the plan that might work just as
well for you. You and your
provider can ask the plan to make an exception for you and cover the drug in
the way you would like it to be covered. If you and your provider want to ask
for an exception, Chapter 7, Section 5.4
tells what to do. Section 9.3 What if you are taking drugs covered by Original Medicare? Your enrollment in the COEHA Medicare Part D Prescription Drug Plan doesn’t affect your coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it, even if you choose not to enroll in Part A or Part B. Some drugs may be covered under Medicare Part B in some situations and through COEHA Medicare Part D Prescription Drug Plan in other situations. Drugs are never covered by both Part B and our plan at the same time. In general, your pharmacist or provider will determine whether to bill Medicare Part B or the COEHA Medicare Part D Prescription Drug Plan for the drug. If you currently have a Medigap policy that includes coverage for prescription drugs, you must contact your Medigap issuer and tell them you have enrolled in our plan. Each year your Medigap insurance company should send you a notice that tells if your prescription drug coverage is “creditable,” and the choices you have for drug coverage. (If the coverage from the Medigap policy is “creditable,” it means that it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) The notice will also explain how much your premium would be lowered if you remove the prescription drug coverage portion of your Medigap policy. If you didn’t get this notice, or if you can’t find it, contact your Medigap insurance company and ask for another copy. Section 9.5 What if you’re also getting drug coverage from an employer or retiree group plan? Do you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group? If so, please contact that group’s benefits administrator. He or she can help you determine how your current prescription drug coverage will work with our plan. In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first. Special
note about ‘creditable coverage’: Each year your employer or retiree group should send you a notice that tells if your prescription drug coverage for the next calendar year is “creditable” and the choices you have for drug coverage. If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn’t get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from the employer or retiree group’s benefits administrator or the employer or union. Section 10.1 Programs to help members use drugs safely Informed RX conducts drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs. Informed RX does a review each time you fill a prescription. They also review your records on a regular basis. During these reviews, they look for potential problems such as:
If Informed RX sees a possible problem in your use of medications, they will work with your provider to correct the problem. Section
10.2
Programs
to help members manage their medications Informed RX has programs that can help our members with special situations. For example, some members have several complex medical conditions or they may need to take many drugs at the same time, or they could have very high drug costs. These programs are voluntary and free to members. A team of pharmacists and doctors developed the programs for Informed RX. The programs can help make sure that our members are using the drugs that work best to treat their medical conditions and help Informed RX identify possible medication errors. If Informed RX has a program that fits your needs, they
will automatically enroll you in the program and send you information. If you
decide not to participate, please notify them and they
will withdraw you from the program. If you have any questions about
these programs, please contact Informed RX Customer Service. CHAPTER FOUR, SECTION 1 Introduction
This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple, we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 3, not all drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law. To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Here are materials that explain these basics:
o This Drug List tells which drugs are covered for you. It also tells which of the three “cost-sharing tiers” the drug is in and whether there are any restrictions on your coverage for the drug. o If you need a copy of the Drug List, call Informed RX Customer Service at 1-866-443-1095. You can also find the Drug List on their website at http://www.myinformedrx.com or on our website at www.coeha.com. The Drug List on the website is always the most current.
As shown in the table below, there are “drug payment stages” for your prescription drug coverage under COEHA Medicare Part D Prescription Drug Plan. How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled. Keep in mind you are always responsible for the plan’s monthly premium regardless of the drug payment stage.
Informed RX keeps track of the costs of your prescription
drugs and the payments you have made when you get your prescriptions filled or
refilled at the pharmacy. This way, we can tell you when you have moved from
one drug payment stage to the next. In particular, there are two types of
costs they keep track of:
Informed RX will prepare a written report called the Explanation of Benefits (it is sometimes called the “EOB”) when you have had one or more prescriptions filled through the plan during the previous month. It includes:
To
keep track of your drug costs and the payments you make for drugs, Informed RX
uses records they get from pharmacies. Here is how you can help Informed RX
keep your information correct and up to date:
o When you purchase a covered drug at an Informed RX network pharmacy at a special price or using a discount card that is not part of our plan’s benefit. o When you have made a copayment for drugs that are provided under a drug manufacturer patient assistance program. o Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances.
The Deductible Stage is the first payment stage for your drug coverage. This stage begins when you fill your first prescription in the year. When you are in this payment stage, you must pay the full cost of your drugs until you reach the plan’s deductible amount, which is $150.00 for 2012.
Once you have paid $150.00 for your drugs, you leave the Deductible Stage and move on to the next drug payment stage, which is the Initial Coverage Stage. During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment). Your share of the cost will vary depending on the drug and where you fill your prescription. The
plan has three
Cost-Sharing Tiers Every drug on the plan’s Drug List is in one of three cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug:
To find out which cost-sharing tier your drug is in, look
it up in the plan’s Drug List. Your
pharmacy choices How much you pay for a drug depends on whether you get the drug from:
For more information about these pharmacy choices and filling your prescriptions, see Chapter 3 in this booklet and the plan’s Pharmacy Directory. During the Initial Coverage Stage, your share of the cost of a covered drug will be a copayment.
As shown in the table below, the amount of the copayment depends on which tier your drug is in. Please note:
Your
share of the cost when you get a one-month
supply (or less) of a covered Part D prescription drug from:
For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is up to a 90-day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 3, Section 2.4.) The table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.
Your
share of the cost when you get a long-term
supply of a covered Part D prescription drug from:
You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled and refilled reaches the $5000.00 limit for the Initial Coverage Stage. Your total drug cost is based on adding together what you have paid and what any Part D plan has paid: · What you have paid for all the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare calculates your out-of-pocket costs.) This includes: o The $150.00 you paid when you were in the Deductible Stage. o The total you paid as your share of the cost for your drugs during the Initial Coverage Stage. · What the plan has paid as its share of the cost for your drugs during the Initial Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2012, the amount that plan paid during the Initial Coverage Stage also counts toward your total drug costs.) We
also provide some over-the-counter medications exclusively for your use. These
over-the-counter drugs are provided at no cost to you. To find out which drugs
our plan covers, refer to your formulary. The Explanation of Benefits (EOB) that we send to you will help you keep track of how much you and the plan have spent for your drugs during the year. Many people do not reach the $5000.00 limit in a year. We will let you know if you reach this $5000.00 limit. If you do reach this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage. SECTION 6
During
the Coverage Gap Stage, you
receive a discount on brand name drugs and pay no more than 86% of the costs
for generic drugs
You also
receive some coverage for generic
drugs. You pay no more than 86% of the cost for generic drugs and the plan
pays the rest. For
generic drugs, the amount paid by the plan (14%) does not count toward your
out-of-pocket costs. Only the amount you pay counts and moves you through the
coverage gap. You continue paying the discounted price for brand name drugs and no more than 86% of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2012, that amount is $4700.00. Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $4700.00, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage. Here are Medicare’s rules that we must follow when we
keep track of your out-of-pocket costs for your drugs.
How can you keep track of your out-of-pocket total?
· Informed RX will help you. The Explanation of Benefits (EOB) report we send to you, upon request, includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $4700.00 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. · Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date. You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4700.00 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. During this stage, the plan will pay most of the cost for your drugs.
o –either – coinsurance of 5% of the cost of the drug o –or – $2.60 copayment for a generic drug or a drug that is treated like a generic. Or a $6.50 copayment for all other drugs.
Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of vaccinations:
What
do you pay for a Part D vaccination? What you pay for a Part D vaccination depends on three things: 1. The type of vaccine (what you are being vaccinated for).
2.
Where you get the vaccine medication. 3.
Who gives you the vaccination shot. What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example:
To show how this works, here are three common ways you might get a Part D vaccination shot. Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Deductible Stage and Coverage Gap Stage of your benefit. Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.) · You will have to pay the pharmacy the amount of your copayment for the vaccine and administration of the vaccine. Situation 2: You get the Part D vaccination at your doctor’s office. ·
When you get the vaccination, you will pay for the entire cost
of the vaccine and its administration. ·
You can then ask our plan to pay our share of the cost by using
the procedures that are described in Chapter 5 of this booklet (Asking us to pay our share of the costs for covered drugs). ·
You will be reimbursed the amount you paid less your normal coinsurance
for the vaccine (including administration) less any difference between
the amount the doctor charges and what we normally pay. (If you get Extra
Help, we will reimburse you for this difference.) Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot. · You will have to pay the pharmacy the amount of your copayment for the vaccine itself. · When your doctor gives you the vaccination shot, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 5 of this booklet. ·
You will be reimbursed the amount charged by the doctor for
administering the vaccine less any difference between the amount the doctor
charges and what we normally pay. (If you get Extra Help, we will reimburse
you for this difference.) The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first at COEHA Customer Service whenever you are planning to get a vaccination (phone numbers are on the front inside cover of this booklet.)
Note: If you receive “Extra Help” from Medicare to pay for your
prescription drugs, the late enrollment penalty rules do not apply to you. You
will not pay a late enrollment penalty, even if you go without
“creditable” prescription drug coverage. You may pay a financial penalty if you did not enroll in a plan offering Medicare Part D drug coverage when you first became eligible for this drug coverage or you experienced a continuous period of 63 days or more when you didn’t have creditable prescription drug coverage. (“Creditable prescription drug coverage” is coverage that meets Medicare’s minimum standards since it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) The amount of the penalty depends on how long you waited to enroll in a creditable prescription drug coverage plan any time after the end of your initial enrollment period or how many full calendar months you went without creditable prescription drug coverage. When you first enroll in the COEHA Medicare Part D Prescription Drug Plan, we let you know the amount of the penalty. We will bill you for this penalty twice every year in June and December. Your late enrollment penalty is considered part of your plan premium. If you do not pay your late enrollment penalty, you could be disenrolled for failure to pay your plan premium. Medicare determines the amount of the penalty. Here is how it works: · First count the number of full months that you delayed enrolling in a Medicare drug plan, after you were eligible to enroll. You can also count the number of full months in which you did not have creditable prescription drug coverage, if the break in coverage was 63 days or more. The penalty is 1% for every month that you didn’t have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%.
There are three
important things to note about this monthly premium penalty:
Even if you have delayed enrolling in a plan offering
Medicare Part D coverage when you were
first eligible, sometimes you do not have to pay the late enrollment penalty. You will not have to
pay a premium penalty for late enrollment if you are in any of these
situations:
The following are not
creditable prescription drug coverage: prescription drug discount cards,
free clinics, and drug discount websites. | For additional information about creditable coverage,
please look in your Medicare &
You 2012 Handbook or call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users call 1-877-486-2048. You can call these
numbers for free, 24 hours a day, 7 days a week. | If
you were without creditable coverage, but you were without it for less
than 63 days in a row. | If
you are receiving “Extra Help” from Medicare. | If you disagree about your late enrollment penalty, you or your representative can ask for a review of the decision about your late enrollment penalty. Generally, you must request this review within 60 days from the date on the letter you receive stating you have to pay a late enrollment penalty. Call COEHA Customer Service at the number on the front inside cover of this booklet to find out more about how to do this. Important: Do not stop paying your late enrollment penalty while you’re waiting
for a review of the decision about your late enrollment penalty. If you do,
you could be disenrolled for failure to pay your plan premiums. Most people pay a standard monthly Part D premium.
However, some people pay an extra amount because of their yearly income. If
your income is $85,000 or above for an individual (or married individuals
filing separately) or $170,000 or above for married couples, you must pay an
extra amount for your Medicare Part D coverage.
If you have to pay an extra amount, the Social Security Administration, not your Medicare plan, will send you a letter telling you what that extra amount will be and how to pay it. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefit check, no matter how you usually pay your plan premium, unless your monthly benefit isn’t enough to cover the extra amount owed. If your benefit check isn’t enough to cover the extra amount, you will get a bill from Medicare. The extra amount must be paid separately and cannot be paid with your monthly plan premium. If your modified adjusted gross income as reported on your IRS tax return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium. If you disagree
about paying an extra amount because of your income, you can ask the Social
Security Administration to review the decision. To find out more about how to
do this, contact the Social Security Administration at 1-800-772-1213 (TTY
1-800-325-0778). CHAPTER 5, SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drug Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). Here
are examples of situations in which you may need to ask our plan to pay you
back. All of these examples are types of coverage
decisions (for more information about coverage decisions, go to Chapter 7 of
this booklet). 1.
When you use an out-of-network pharmacy to get a prescription filled If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. · Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 2.
When you pay the full cost for a prescription because you don’t have
your plan membership card with you If you do not have your plan membership card with you when you fill a prescription at an Informed RX pharmacy, you may need to pay the full cost of the prescription yourself. The pharmacy can usually call the plan to get your member information, but there may be times when you may need to pay if you do not have your card. · Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 3.
When you pay the full cost for a prescription in other situations You may pay the full cost of the prescription because you find that the drug is not covered for some reason. · For example, the drug may not be on the plan’s List of Covered Drugs (Formulary); or it could have a requirement or restriction that you didn’t know about or don’t think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it. ·
Save your receipt and send a copy to us when you ask us to pay
you back. In some situations, we may need to get more information from your
doctor in order to pay you back for our share of the cost. 4.
If you are retroactively enrolled in our plan. Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first day of their enrollment has already past. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our
plan and you paid out-of-pocket for any of your drugs after your enrollment
date, you can ask us to pay you back for our share of the costs. You will need
to submit paperwork for us to handle the
reimbursement. ·
Please call COEHA Customer Service for
additional information about how to ask us to pay you back and deadlines for
making your request. All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 7 of this booklet (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) has information about how to make an appeal. Send us your request for payment, along with your receipt documenting the payment you have made. It’s a good idea to make a copy of your receipts for your records. Mail your request for payment together with any receipts to us at this address: C and O Employees’ Hospital Association 511 Main Street, 2nd floor Clifton Forge, VA 24422 You may also call our plan to request payment. For details, go to Chapter 2, Section 1 and look for the section called, How to contact our plan’s Customer Service. Please be sure to contact COEHA Customer Service if you have any questions. If you don’t know what you should have paid, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us. When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.
If you think we have made a mistake in turning down your request for payment or you don’t agree with the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment. The examples of situations in which you may need to ask our plan to pay you back:
For the details on how to make this appeal, go to Chapter 7 of this booklet (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). The appeals process is a formal process with detailed procedures and important deadlines. If making an appeal is new to you, you will find it helpful to start by reading Section 4 of Chapter 7. Section 4 is an introductory section that explains the process for coverage decisions and appeals and gives definitions of terms such as “appeal.” After you have read Section 4, you can go to Section 5.5 in Chapter 7 for a step-by-step explanation of how to file an appeal. There are some situations when you should let us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we can calculate your out-of-pocket costs correctly. This may help you to qualify for the Catastrophic Coverage Stage more quickly. Here are two situations when you should
send us copies of receipts to let us know about payments you have made for
your drugs: 1.
When you buy the drug for a price that is lower than our price Sometimes when you are in the Deductible Stage and Coverage Gap Stage you can buy your drug at an Informed RX pharmacy for a price that is lower than our price. · For example, a pharmacy might offer a special price on the drug; or you may have a discount card that is outside our benefit that offers a lower price. · Unless special conditions apply, you must use an Informed RX pharmacy in these situations and your drug must be on our Drug List. · Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. · Please note: If you are in the Deductible Stage and Coverage Gap Stage, the plan will not pay for any share of these drug costs. Sending a copy of the receipt allows us to assist Informed RX in calculating your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly. 2.
When you get a drug through a patient assistance program offered by a
drug manufacturer Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside the plan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a copayment to the patient assistance program. · Save your receipt and send a copy to us so that we can assist Informed RX in having your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. · Please note: Because you are getting your drug through the patient assistance program and not through the plan’s benefits, the plan will not pay for any share of these drug costs. Sending a copy of the receipt allows us to assist Informed RX in calculating your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly. Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Therefore, you cannot make an appeal if you disagree with our decision. CHAPTER
6, SECTION 1 Our plan must honor
your rights as a member of the plan
Section 1.1 We must treat you with fairness and respect at all times Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. If you have a disability and need help with access to care, please call us at COEHA Customer Service (phone numbers are on the front inside cover of this booklet). If you have a complaint, such as a problem with wheelchair access, COEHA Customer Service can help. As a member of our plan, you also have the right to get your prescriptions filled or refilled at any of the Informed RX network pharmacies without long delays. If you think that you are not getting your Part D drugs within a reasonable amount of time, Chapter 7, Section 7 of this booklet tells what you can do. (If we have denied coverage for your prescription drugs and you don’t agree with our decision, Chapter 7, Section 4 tells what you can do.) Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.
How
do we protect the privacy of your health information?
You
can see the information in your records and know how it has been shared with
others You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have
questions or concerns about the privacy of your personal health information,
please call COEHA Customer Service (phone numbers are on the front inside
cover of this booklet). Section 1.4 We must give you information about the plan, its network of pharmacies, and your covered drugs As a member of our plan, you have the right to get several kinds of information from us. (As explained above in Section 1.3, you have the right to get information from us.) If you want any of the following kinds of information, please call COEHA Customer Service (phone numbers are on the front inside cover of this booklet):
Information about your coverage and rules you
must follow in using your coverage. |
Information about why something is not covered
and what you can do about it. |
You
have the right to give instructions about what is to be done if you are not
able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:
The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives. If you want to use an “advance directive” to give your instructions, here is what to do:
If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.
Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What
if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with the appropriate state agency. Section 1.6 You have the right to make complaints and to ask us to reconsider decisions we have made If you have any problems or concerns about your covered services or care, Chapter 7 of this booklet tells what you can do. It gives the details about how to deal with all types of problems and complaints. As explained in Chapter 7, what you need to do to follow
up on a problem or concern depends on the situation. You might need to ask our
plan to make a coverage decision for you, make an appeal to us to change a
coverage decision, or make a complaint. Whatever you do – ask for a coverage
decision, make an appeal, or make a complaint – we are required to treat you fairly. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call COEHA Customer Service (phone numbers are on the front inside of this booklet). If it is about discrimination, call the Office for Civil Rights | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||