|
| | 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
January
1 – December 31, 2010
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, 2010. It
explains how to get the prescription drugs you need. This is an
important legal document. Please keep it in a safe place.
C and O Employees’ Hospital Association Customer Services:
For help or information, please call Customer Service or go to our plan website
at www.coeha.com.
Calls to these numbers are free: 1-800-679-9135 and
Local residents in the Clifton Forge, VA area: 862-5728
TTY/TDD users call: 711 for all states
This plan is offered by C and O Employees’ Hospital
Association ("COEHA"), referred throughout the Evidence of Coverage as
"we," "us," or "our." C and O Employees’
Hospital Association Medicare Part D Prescription Drug Plan is referred to as
"plan" or "our plan."
The COEHA has a contract with the Federal Government
to provide our members with an enhanced Medicare Part D
Prescription Drug Plan.
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.
Chapter 1. Getting started as a
member of
C and O Employees' Hospital Association Medicare Part D Prescription Drug
Plan 7
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 23
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, 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 38
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 your
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 66
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.
Tells about the late enrollment penalty.
Chapter 5. Asking the plan to pay
its share of the costs for covered drugs 89
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 drugs.
Chapter 6. Your rights and
responsibilities 96
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) 108
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
145
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 notice 156
Includes notices about governing law and about
nondiscrimination.
Chapter 10. Definitions of
important words 157
Explains key terms used in this booklet.
SECTION
1 Introduction
Section
1.1 What is the Evidence of Coverage booklet about?
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.
 | 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. |
This plan is offered by C and O Employees’ Hospital
Association ("COEHA"), referred throughout the Evidence of Coverage as
"we," "us," or "our." C and O Employees’
Hospital Association Medicare Part D Prescription Drug Plan is referred to as
"plan" or "our 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.
Section
1.2 What does this Chapter tell you?
Look through Chapter 1 of this Evidence of Coverage to
learn:
Section
1.3 What if you are new to C and O Employees’ Hospital
Association Medicare Part D Prescription Drug Plan?
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 Services (contact information is on the
inside cover of this booklet).
Section
1.4 Legal information about the Evidence of Coverage
It’s part of our contract with you
This Evidence of Coverage is part of our contract with
you about how C and O Employees’ Hospital Association Medicare Part D
Prescription Drug Plan covers your care. Other parts of this contract
include your enrollment form, and any notices you receive from us about changes
or extra conditions that can affect your
coverage. These notices are sometimes called "riders" or
"amendments."
The contract is in effect for months in which you are
enrolled in
C and O employees’ Hospital Association Medicare Part D Prescription Drug Plan
between January 1, 2010 to December 31, 2010.
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.
SECTION
2 What makes you eligible to be a plan member?
Section
2.1 Your eligibility requirements
You are eligible for membership in our plan as long as:
| You are enrolled in the Original Medicare Plan, Parts A and B. If you
currently pay a premium for Medicare Part A and or Medicare Part B, you must
continue paying your premium in order to keep your Medicare Part A and /or
Medicare Part B and remain a member of this plan and also fall in one of the
following categories: |
Former COEHA member who discontinued membership in
COEHA, including those who were
employees of the former C&O Hospitals in Clifton Forge, VA and
Huntington, WV
Medicare spouse of COEHA member
Medicare widow (er) of COEHA member
Medicare spouse/widow(er) of former COEHA member
Medicare dependent child of COEHA member or former
COEHA member
Medicare divorcee of COEHA member (as long as they have
not remarried)
Medicare parent or parent-in-law of COEHA
member
Retiree from any Railroad
Section
2.2 What are Medicare Part A and Medicare Part B?
When you originally signed up for Medicare, you received
information about how to get Medicare Part A and Medicare Part B. Remember:
| Medicare Part A generally covers services furnished by providers such as
hospitals, skilled nursing facilities or home health agencies. |
| Medicare Part B is for most other medical services, such as physician’s
services and other outpatient services. |
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
While
you are a member of our plan, you must use the Informed RX membership card for
prescription drugs you get at network pharmacies. Here’s a sample membership
card to show you what yours will look like:
If you have a membership card which still shows NMHC RX, you
may use this card. Please carry your card with you at all times and remember
to show your card when you get covered drugs. If your plan membership card is
damaged, lost, or stolen, call Informed RX Customer Service right away and they
will send you a new card.
You may need to use your red, white, and blue Medicare card
to get covered medical care and services under Original Medicare.
Section
3.2 The Pharmacy Directory: your guide to pharmacies in our
network
What
are "network pharmacies"?
As a member of our Plan, Informed RX will send you a Pharmacy
Directory, which gives you a list of their main network
pharmacies—that 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 their network pharmacies if you
want our plan to cover (help you pay for) them. Informed RX will send you a
Pharmacy Directory at least once every three years.
If you don’t have the Pharmacy Directory, you can get a
copy from Informed RX Customer Service. They can also give you the most
up-to-date information about changes in their pharmacy network, which can change
during the year. You can also find this information on their web site,
https://informedrx.rxportal.sxc.com/rxclaim/portal/preLogin.
Section
3.3 The plan’s List of Covered Drugs (Formulary)
The plan has a List of Covered Drugs (Formulary). We
call it the "Drug List" for short. It tells which Part D prescription
drugs are covered 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.
To get the most complete and current information about which
drugs are covered, you can visit the plan’s website, www.coeha.com,
or call Informed RX Customer Service at
1-866-443-1095.
Section
3.4 Reports with a summary of payments made for your prescription
drugs
When you use your prescription drug benefits, we will send
you a report, upon request, to help you understand and keep track of payments
for your prescription drugs. This summary report is called the Explanation of
Benefits.
The Explanation of Benefits tells you the total amount
you have spent on your prescription drugs and the total amount we have paid for
each of your 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
Section
4.1 How much is your plan premium?
As a member of this plan, you pay a monthly plan premium,
which also includes payment for your membership in the COEHA Supplemental Plan.
At the current time your monthly premium is $250.00 per month. If your premium
changes for 2010, it will be listed in the 2010 COEHA Medicare Part D
Prescription Drug Plan Annual Notice of Change.
In some situations, your
plan premium could be less
There are programs to help people with limited resources pay
for their drugs. Chapter 2, Section 7 tells more about these programs. If you
qualify for one of these programs, enrolling in the program might make your
monthly plan premium lower than $250.00.
If you are already enrolled and getting help from one
of these programs, some of the payment information in this Evidence of
Coverage may not apply to you. We have included 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 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 cover.
In some situations, your plan premium could be more
Some members are required to pay a late enrollment penalty
because they did not join a Medicare drug plan when they first became eligible
or because they had a continuous period of 63 days or more when they didn’t
keep their coverage. For these members, the plan’s monthly premium will be
higher. It will be the monthly plan premium plus the amount of their late
enrollment penalty.
If you are required to pay the late enrollment penalty, the
amount of your penalty depends on how long you waited before you enrolled in
drug coverage or how many months you were without drug coverage after you became
eligible. Chapter 4, Section 10 explains the late enrollment penalty.
Many members are required to pay other Medicare premiums
In addition to paying the monthly plan premium, 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. You must continue paying your Medicare
Part B premium for you to remain as a member of the plan.
| Your copy of Medicare & You 2010 tells about these
premiums in the section called "2010 Medicare Costs." This
explains how the Part B premium differs for people with different incomes. |
| Everyone with Medicare receives a copy of Medicare & You each
year in the fall. Those new to Medicare receive it within a month after
first signing up. You can download a copy of Medicare & You 2010
from the Medicare website (http://www.medicare.gov).
You can also order a printed copy by phone at 1-800-MEDICARE
(1-800-633-4227) 24 hours a day, 7 days a week. TTY users call
1-877-486-2048. |
Section
4.2 There are two
ways you can pay your plan premium
There are two ways you can pay your plan premium.
Option 1: You can pay by check
You may decide to pay your monthly 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 each month. 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 2: Automatic dues deduction
Instead of paying by check, you can have your monthly plan
premium automatically withdrawn from your bank account on the fifth (5th)
day of each month.
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’.
What to do if you are having trouble paying your plan premium
Your plan premium is due in our office by the 5th
day 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 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 of
non-payment of premiums, and you don’t currently have prescription drug
coverage then you will not be able to receive Part D coverage 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 we end your membership due to non-payment of premiums, you
will have 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, you will need to pay these late premiums before you
can enroll.
Section
4.3 Can we change your monthly plan premium during the year?
No.
We are not allowed to change the amount we
charge for the plan’s monthly plan premium during the year. If the monthly
plan premium changes for next year we will tell you in October 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 Extra Help or if you lose your eligibility for Extra Help
during the year. If a member qualifies for Extra Help with their
prescription drug costs, Extra Help 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 Extra Help in Chapter 2, Section 7.
What if you believe you have qualified for "Extra
Help"
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.
Please call COEHA Customer Service at the number listed on
the inside cover of the book for assistance. We will accept any of the
following forms of evidence to establish your qualifications for Extra Help
when it is provided by you, your pharmacist, advocate, representative, family
member or other individual acting on your behalf:
| A copy of the beneficiary’s Medicaid card that includes the
beneficiary’s name and an eligibility date during a month after June of
the previous calendar year; |
| A copy of a state document that confirms active Medicaid status during a
month after June of the previous calendar year; |
| A printout from the State electronic enrollment file showing Medicaid
status during a month after June of the previous calendar year; |
| A screen print from the State’s Medicaid systems showing Medicaid
status during a month after June of the previous calendar year; |
| Other documentation provided by the State showing Medicaid status during
a month after June of the previous
calendar year; or, |
| For individuals who are not deemed eligible, but who apply and are found
LIS eligible, a copy of the SSA award letter. |
When we receive the evidence showing your copayment level,
we will update our system so that you can pay the correct copayment when you
get your next prescription at the pharmacy. If you overpay your copayment, we
will reimburse you. Informed Rx will forward a check to you in the amount of
your overpayment. If the pharmacy hasn’t collected a copayment from you and
is carrying your copayment as a debt owed by you, they will reprocess your
claim. If a state paid on your behalf, Informed RX may make payment directly
to the state. Please contact COEHA Customer Service if you have any questions.
SECTION
5 Please keep your plan membership record up to date
Section
5.1 How to help make sure that we have accurate information about you
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 Informed RX 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.
Call COEHA Customer Service to 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 |
Read over the information we send you about any other insurance
coverage you have
Medicare requires that we collect information from you about
any other medical or drug insurance coverage you have. We must coordinate any
other coverage you have with your benefits under our plan. From time to time, we
will send you a "Coordination of Benefits Questionnaire" to complete.
You should complete and return this Questionnaire even though you may not have
other
insurance in addition to us and Medicare.
SECTION
1 C and O Employees’ Hospital Association Medicare Part D
Prescription Drug Plan
contacts
(how
to contact us, including how to reach Customer Service at the plan)
How to contact our plan’s Customer Service
For assistance with claims, billing or member card questions,
please call or write to C and O Employees’ Hospital Association Customer
Service. We will be happy to help you.
|
Customer Service |
CALL
|
1-800-679-9135 or local residents in the
Clifton Forge, VA area call 862-5728.
Calls to this number are free. Our
hours of operation are Monday through Friday, 8:30 am to 5:00 pm (EST) |
TTY/TDD
|
Call 711 for all states
|
FAX
|
1-540-862-3552 or 1-540-862-4958 |
WRITE
|
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, VA 24422 |
WEBSITE
|
www.coeha.com |
How to contact us when you are asking for a
coverage decision about your Part D prescription drugs, appeals and complaints
You may call us if you have questions about our coverage
decision process.
|
Coverage Decisions for Part D Prescription Drugs |
CALL
|
1-800-679-9135 or local residents in the
Clifton Forge, VA area call 862-5728.
Calls to this number are free. Our
hours of operation are Monday through Friday, 8:30 am to 5:00 pm (EST) |
TTY/TDD
|
Call 711 for all states |
FAX
|
1-540-862-3552 or 1-540-862-4958 |
WRITE
|
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, VA 24422
|
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).
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).
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).
Where to send a request that asks us to pay for our share of the
cost of a
drug you have received
The coverage determination process includes determining
requests that ask 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 the plan to pay its share of the cost of a drug).
|
Payment Requests |
CALL
|
1-800-679-9135 or local residents in the
Clifton Forge, VA area call 862-5728.
Calls to this number are free. Our
hours of operation are Monday through Friday, 8:30 am to 5:00 pm (EST) |
TTY/TDD
|
Call 711 for all states
|
FAX
|
1-540-862-3552 or 1-540-862-4958 |
WRITE
|
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, VA 24422
|
SECTION
2 Medicare
(how
to get help and information directly from the Federal Medicare
program)
Medicare is the Federal health insurance program for people
65 years of age or older, some people under age 65 with disabilities, and people
with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The Federal agency in charge of Medicare is the Centers for
Medicare & Medicaid Services (sometimes called "CMS"). This agency
contracts with Medicare Prescription Drug Plans,
including us.
|
Medicare |
CALL
|
1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week. |
TTY
|
1-877-486-2048
This number requires special telephone equipment and is
only for people who have difficulties with hearing or speaking.
Calls to this number are free. |
WEBSITE
|
http://www.medicare.gov
This is the official government website for Medicare.
It gives you up-to-date information about Medicare and current
Medicare issues. It also has information about hospitals, nursing homes,
physicians, home health agencies, and dialysis facilities. It includes
booklets you can print directly from your computer. It has tools to help
you compare Medicare Advantage Plans and Medicare drug plans in your area.
You can also find Medicare contacts in your state by
selecting "Helpful Phone Numbers and Websites."
If you don’t have a computer, your local library or
senior center may be able to help you visit this website using its
computer. You can call Medicare at the number above and tell them what
information you are looking for. They will find the information on the
website, print it out, and send it to you. |
SECTION
3 State Health Insurance Assistance Program
(free
help, information, and
answers to your questions about Medicare)
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.
|
State Health Insurance Assistance Program (SHIP) |
CALL
|
Call the national Medicare
@ 1-800-633-4227 |
TTY
|
Call 1-877-486-2048 |
WEBSITE
|
www.medicare.gov |
SECTION
4 Quality Improvement
Organization
(paid
by Medicare to check on the quality of care for people with
Medicare)
There is a Quality Improvement Organization (QIO) in 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. The QIO
is an independent organization. It is not connected with our plan.
You should contact the QIO in any of these situations:
| You have a complaint about the quality of care you have received. |
| You think coverage for your hospital stay is ending too soon. |
| You think coverage for your home health care, skilled nursing facility
care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services
are ending too soon. |
|
Quality Improvement Organization (QIO) |
CALL
|
Call the national Medicare @ 1-800-633-4227 |
TTY
|
Call 1-877-486-2048 |
WEBSITE
|
www.medicare.gov |
SECTION
5 Social Security
Social Security 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 and pay the Part B premium.
Social Security handles the enrollment process for Medicare. To apply for
Medicare, you can call Social Security or visit your local Social Security
office.
|
Social Security Administration |
CALL
|
1-800-772-1213
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
You can use our automated telephone
services to get recorded information and conduct some business 24 hours a
day. |
TTY
|
1-800-325-0778
This number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.
Calls to this number are free.
Available 7:00 am ET to 7:00 pm, Monday through Friday. |
WEBSITE
|
http://www.ssa.gov |
SECTION 6 Medicaid
(a
joint Federal and state program that helps with medical costs for
some people with limited income and resources)
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. Medicaid has programs
that can help pay for your Medicare premiums and other costs, if you qualify. To
find out more about Medicaid and its programs, contact your State Medical
Assistance office or the national Medicare.
|
Medicaid |
CALL
|
Call the national Medicare
@ 1-800-633-4227 |
TTY
|
1-877-486-2048 |
WEBSITE
|
www.medicare.gov |
SECTION 7 Information about
programs to help people pay for their
prescription drugs
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.
If you think you may qualify for Extra Help, call Social
Security (see Section 5 of this chapter for contact information) to apply for
the program. You may also be able to apply at your State Medical Assistance or
Medicaid Office (see Section 6 of this chapter for contact information). After
you apply, you will get a letter letting you know if you qualify for Extra Help
and what you need to do next.
State Pharmaceutical Assistance Programs (SPAP)
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.
SPAP is a state organization
that provides limited income and medically needy seniors and individuals with
disabilities financial help for prescription drugs.
|
State Pharmaceutical Assistance Programs (SPAP) |
CALL
|
Call the national Medicare
@ 1-800-633-4227 |
TTY
|
Call 1-877-486-2048 |
WEBSITE
|
www.medicare.gov |
SECTION 8 How to contact the
Railroad Retirement Board
The Railroad Retirement Board is an independent Federal
agency that administers comprehensive benefit programs for the nation’s
railroad workers and their families. If you have questions regarding your
benefits from the Railroad Retirement Board, contact the agency.
|
Railroad Retirement Board |
CALL
|
1-877-772-5772
Calls to this number are free.
Available 9:00 am to 3:30 pm, Monday through Friday
If you have a touch-tone telephone, recorded information
and automated services are available 24 hours a day, including weekends
and holidays. |
TTY
|
1-312-751-4701
This number requires special telephone equipment and is
only for people who have difficulties with hearing or speaking.
Calls to this number are not free. |
WEBSITE
|
http://www.rrb.gov |
SECTION 9 Do you have
"group insurance" or other health insurance from an
employer?
If you (or your spouse) get benefits from your (or your spouse’s) employer
or retiree group, call the employer/union benefits administrator or
Member/Customer Services if you have any questions. You can ask about your (or
your spouse’s) employer or retiree health or drug benefits, premiums, or
enrollment period.
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.
|
? |
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, Section 7.
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 may not apply to you. We
have included 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 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 front inside cover. |
SECTION 1 Introduction
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. |
| Medicare Part B also provides benefits for some drugs. Part B drugs
include certain chemotherapy drugs, certain drug injections you are given
during an office visit, and drugs you are given at a dialysis facility. |
The two examples of drugs described above are covered by
Original Medicare. To find out more about this coverage, see your Medicare
& You handbook.
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:
| You must use a network pharmacy to fill your prescription. (See Section 2,
Fill your prescriptions at a network pharmacy.) |
| Your drug must be on the plan’s List of Covered Drugs (Formulary)
(we call it the "Drug List" for short). (See Section 3, Your
drugs need to be on the plan’s drug list.) |
| Your drug must be considered "medically necessary", meaning
reasonable and necessary for treatment of your illness or injury. It also
needs to be an accepted treatment for your medical condition. |
SECTION
2 Fill your prescription at a network pharmacy or through the plan’s
mail-order service
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 the plan’s network pharmacies.
A network pharmacy is a pharmacy that has a contract with the
plan to provide your covered prescription drugs. The term "covered
drugs" means all of the Part D prescription drugs that are covered by the
plan.
Section 2.2
Finding network pharmacies
How do you find a network pharmacy in your area?
You can look in your Pharmacy Directory, visit the
Informed RX web site, http://informedrx.rxportal.sxc.com/rxclaim/portal/preLogin,callor
Informed RX Customer Service. 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 either 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 non-retail, network pharmacy?
Sometimes prescriptions must be filled at a non-retail,
network pharmacy. Non-retail, network pharmacies include:
| Pharmacies that supply drugs for home infusion
therapy. |
| Pharmacies that supply drugs for residents of a long-term-care facility.
Usually, a long-term care facility (such as a nursing home) has its own
pharmacy.
Residents may get prescription drugs through the
facility’s pharmacy as long as it is part of the Informed RX network. If
your long-term care pharmacy is not in the Informed RX network, please
contact Informed RX Customer Service |
| Pharmacies that dispense certain drugs that are
restricted by the FDA to certain locations, require
extraordinary handling, provider coordination, or
education on its use. (Note: This scenario should
happen rarely.) |
To locate a non-retail, network 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 requires
you to order a 90-day supply of the drug.
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 plan’s 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 Services 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 drugs on our
plan’s Drug List. Mail-order drugs are drugs that
you take on a regular basis, for a chronic or long-term medical condition.
- Some retail pharmacies
in our network allow you to get a long-term
supply of mail-order drugs. Some of these retail pharmacies may agree to
accept the mail-order cost-sharing amount for a long-term supply of mail-order
drugs. Other retail pharmacies may not agree to accept the mail-order
cost-sharing amounts for an extended supply of mail-order drugs. In this case
you will be responsible for the difference in price. All
Walmart, Kroger, Rite-Aid and Target Pharmacies will handle 90-day fills for
mail-order copayments. You can also call COEHA Customer Service for
more information on other pharmacies who participate in a 90-day fill for
mail-order copayment.
- You can use the plan’s network mail-order services. Our plan’s
mail-order service requires you to order a 90-day supply of the drug. See
Section 3.3 for more information about using our mail-order services.
Section
2.5 When can you use a pharmacy that is not in the plan’s network?
Your prescription might 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 paying 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 Your drugs need to be on the plan’s "Drug List"
Section
3.1 The "Drug List" tells which Part D drugs are covered
The
plan has a "List of Covered Drugs (Formulary)." In this Evidence
of Coverage, we call it the "Drug List" for short.
The drugs on this list are selected by the plan with the help
of a team of doctors and pharmacists. The list 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 the
drug is medically necessary, meaning reasonable and necessary for treatment of
your illness or injury. It also needs to be an
accepted treatment for your medical condition.
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. It works just as well as the brand-name
drug, but it 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 8.1 in this chapter). |
| In other cases, we have decided not to include a particular drug on our
Drug List. |
Section
3.2 How can you find out if a specific drug is on the Drug List?
You have three ways to find out:
- Visit the plan’s website, www.coeha.com.
The Drug List on the website is always the most current.
- 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.
SECTION
4 There are restrictions on coverage for some drugs
Section
4.1 Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how
and when the plan covers them. A team of doctors and pharmacists developed these
rules to 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 get a drug that works for
your medical condition and is safe. 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 doctor or other prescriber to use that lower-cost option.
We also need to comply with Medicare’s rules and regulations for drug coverage
and cost sharing.
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.
Using generic drugs whenever you can
A "generic" drug works the same as a brand-name
drug, but
usually costs less. When a generic version of a brand-name drug is available,
our network pharmacies must provide you the generic version. However, if
your doctor has told us the medical reason that the generic drug will not work
for you, then we will cover the brand-name drug. (Your share of the cost may be
greater for the brand-name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your doctor need to get approval
from the plan before we will agree to cover the drug for you. This is called
"prior authorization." Sometimes plan approval is required so
we can be sure that your drug is covered by Medicare rules. 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.
Trying a different drug first
This requirement encourages you to try safer or more
effective drugs before the plan covers another drug. For example, if Drug A and
Drug B treat the same medical condition, the plan may require you to try Drug A
first. If Drug A does not work for you, the plan will then cover Drug B. This
requirement to try a different drug first is called "Step Therapy."
Quantity limits
For certain drugs, we limit 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 COEHA Customer Service (phone numbers are on the front inside
cover) or check our website:
www.coeha.com.
SECTION
5 What if one of your drugs is not covered in the way you’d like
it to be covered?
Section
5.1 There are things you can do if your drug is not covered in the
way you’d like it to be covered
Suppose there is a prescription drug you are currently
taking, or one that you and your doctor 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, you
might be
required to try a different drug first, to see if it will work, before the
drug you want to take will be covered for you or there might be limits on what
amount of the drug (number of pills, etc.) is covered during a particular time
period. |
There are things you can do if your drug is not covered in
the way that you’d like it to be covered. If your drug is not on the Drug List
or if your drug is restricted, go to Section 5.2 to learn what you can do.
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) until you
and your doctor decide it is okay to change to another drug, or while you
file an exception. |
| 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 covered. |
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 doctor
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:
| For those members who are new to the plan and aren’t in a long-term care
facility: |
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 a network pharmacy.
| For those who are new members, and are residents in a long-term care
facility: |
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.
| For those who have been a member of the plan for more than 90 days
and are a resident of a long-term care
facility and need a supply right away: |
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.
To ask for a temporary supply, call COEHA Customer Service
(phone numbers are on the front inside cover).
During the time when you are getting a temporary supply of a
drug, you should talk with your doctor or other prescriber 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 doctor can ask
the plan to make an exception for you and cover the drug in the way you would
like it to be covered. The sections below tell you more about these options.
You can change to another drug
Start by talking with your doctor or other prescriber.
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
doctor to find a covered drug that might work for you.
You can file an exception
You and your doctor or other prescriber 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 doctor or other prescriber says that you have medical reasons
that justify asking us for an exception, your doctor or other prescriber 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 doctor or other prescriber want to ask for an
exception, Chapter 7 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.
You can file an exception
You and your doctor or other prescriber can ask the plan to
make an exception in the cost-sharing
tier for the drug so that you pay less for the drug. If
your doctor or other prescriber says that you have medical reasons that justify
asking us for an exception, your doctor or other prescriber can help you request
an exception to the rule.
SECTION
6 What if your coverage changes for one of your drugs?
Section
6.1 The Drug List can change during the year
Most of the changes in drug coverage happen at the beginning
of each year (January 1). However, during the year, the plan 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. |
| 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 Informed RX will send you a notice to tell you. Normally, they 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. Informed RX will let you
know of this change right away. Your doctor 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 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. |
| During this 60-day period, you should be working with your doctor to
switch to the generic or to a different drug that we cover. |
| You and your doctor or other prescriber 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). |
| Again, 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. |
| Your doctor or other prescriber will also know about this change, and
can work with you to find another drug for your condition. |
SECTION
7 What types of drugs are not covered by the plan?
Section
7.1 Types of drugs we do not cover
This section tells you what kinds of prescription drugs are
"excluded." Excluded means that the plan doesn’t cover these types
of drugs because the law doesn’t allow any Medicare drug plan to cover them.
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 (unless
our plan covers certain excluded drugs). 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
because of your specific situation. (For information about appealing a decision
we have made to not cover a drug, go to Chapter 9 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. |
| "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. |
| Sometimes "off-label use" is allowed. Medicare sometimes
allows us to cover "off-label uses" of a prescription drug.
Coverage 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 unless we offer enhanced drug coverage, for which you may be
charged an additional premium:
| Non-prescription drugs (also called over-the-counter drugs) with the
exception of Prilosec OTC, Claritin OTC and Zyrtec 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. As listed above under
Non-prescription drugs, we do cover the following over-the-counter drugs:
| Prilosec OTC |
| Claritin OTC |
| Zyrtec OTC |
There is no copayment due by you for these drugs, therefore,
these drugs do not count towards qualifying you for the Catastrophic Coverage
Stage. (The Catastrophic Coverage Stage is described in Chapter 4, Section 7 of
this booklet.)
If you receive extra help paying for your drugs, 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.
SECTION
8 Show your plan membership card when you fill a prescription
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 plan membership card 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 Part D drug coverage in special situations
Section
9.1 What if you’re in a hospital or a skilled nursing facility for
a stay that is covered by the plan?
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, indicates 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 the Informed RX network. If it
isn’t, or if you need more information, please contact Informed RX
Customer Service.
What if you’re 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 doctor or other prescriber 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 doctor 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
doctor want to ask for an exception, Chapter 7 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 Part D 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 the COEHA Medicare Part D Prescription Drug Plan in other
situations. But drugs are never covered by both Part B and our plan Part D 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.
Section 9.4 What if you have
a Medigap (Medicare Supplement Insurance) policy with prescription
drug coverage?
If you currently have a Medigap policy that includes coverage
for prescription drugs, you must contact your Medigap issuer and tell them you
have enrolled in our plan.
Each year your Medigap insurance company should send you a
notice by November 15 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 has drug coverage that pays,
on average, at least as much as Medicare’s standard drug coverage.) If
you didn’t get this notice, or if you can’t find it, contact your Medicare
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 by November 15 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 it has drug coverage that
pays, on average, at least as much as Medicare’s standard 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 Programs on drug safety and managing medications
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 their records on a regular basis. During these reviews, they
look for potential problems such as:
| Possible medication errors. |
| Drugs that may not be necessary because you are taking another drug to
treat the same medical condition. |
| Drugs that may not be safe or appropriate because of your age or gender. |
| Certain combinations of drugs that could harm you if taken at the same
time. |
| Prescriptions written for drugs that have ingredients you are allergic to. |
| Possible errors in the amount (dosage) of a drug you are taking. |
If Informed RX sees a possible problem in your use of
medications, they will work with your doctor 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 them 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 us and we will withdraw your participation in
the program.
|
? |
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. OR The "Extra Help" program helps
people with limited resources pay for their drugs. For more information,
see Chapter 2, Section 7.
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 may not apply to you. We
have included 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 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 front inside cover. |
SECTION 1 Introduction
Section 1.1 Use this chapter
together with other materials that explain your drug coverage
This chapter focuses on what you pay for 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, some
drugs are covered under Original Medicare or are excluded 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:
| The plan’s List of Covered Drugs (Formulary). To keep things
simple, we call this the "Drug List." |
| This Drug List tells which drugs are covered for you. |
| 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 our website at www.coeha.com.
The Drug List on the website is always the most current. |
| Chapter 3 of this booklet. Chapter 3 gives the details about your
prescription drug coverage, including rules you need to follow when you get
your covered drugs. Chapter 3 also tells which types of prescription drugs are
not covered by our plan. |
| The plan’s Pharmacy Directory. In most situations you must
use a network pharmacy to get your covered drugs (see Chapter 3 for the
details). The Pharmacy Directory has a list of pharmacies in the plan’s
network and it tells how you can use the plan’s mail-order service to get
certain types of drugs. It also explains
how you can get a long-term supply of a drug (such as filling a prescription
for a three month’s supply). |
SECTION
2 What you pay for a drug
depends on which "drug payment stage" you are in when you
get the drug
Section
2.1 What are the four
drug payment stages?
As shown in the table below, there are four "drug
payment
stages" for your prescription drug coverage. 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.
|
Stage 1
Yearly
Deductible Stage |
Stage 2
Initial
Coverage Stage |
Stage 3
Coverage Gap Stage |
Stage 4
Catastrophic Coverage Stage |
|
You begin in this payment stage when you fill your first
prescription of the year.
During this stage you pay the full cost of your
drugs.
You stay in this stage until you have paid $150.00
for your drugs ($150.00 is the amount
of your deductible).
(Details are in Section 4 of this chapter.)
|
The plan pays its share of the cost of your drugs and you
pay your share of the cost.
You stay in this stage until your payments for the year
plus the plan’s payments total $5000.00.
(Details are in Section 5 of this chapter.)
|
You pay the full cost of your drugs.
You stay in this stage until your "out-of-pocket
costs" reach a total of $4550.00.
This amount and rules for counting costs toward this
amount have been set by Medicare.
(Details are in Section 6 of this chapter.) |
Once you have paid enough for your drugs to move on to
this last payment stage, the plan will pay most of the cost of your
drugs for the rest of the year.
(Details are in Section 7 of this chapter.)
|
As shown in this summary of the four payment stages, whether
you move on to the next payment stage depends on how much you and/or the plan
spends for your drugs while you are in each stage.
SECTION
3 You can request reports that explain payments for your drugs and
which payment stage you are in
Section
3.1 You can request a monthly report called the "Explanation of
Benefits"
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 we
keep track of:
| We keep track of how much you have paid. This is called your "out-of-pocket"
cost. |
| We keep track of your "total drug costs." This is the
amount you pay out-of-pocket or others pay on your behalf plus the amount
paid by the plan. |
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. It includes:
| Information for that month. This report gives the payment details
about the prescriptions you have filled during the previous month. It shows
the total drugs costs, what the plan paid, and what you and others on your
behalf paid. |
| Totals for the year since January 1. This is called
"year-to-date" information. It shows you the total drug costs and
total payments for your drugs since the year began. |
Section
3.2 Help us keep our information about your drug payments up to date
To keep track of your drug costs and the payments you make
for drugs, Informed RX uses records they get from pharmacies. Here is how you
can help Informed RX keep your information correct and up to date:
| Show your membership card when you get a prescription filled. To make
sure Informed RX knows about the prescriptions you are filling and what you
are paying, show your plan membership card every time you get a prescription
filled. |
| Make sure we have the information we need. There are times you may pay
for prescription drugs when we will not automatically get the information we
need. To help us keep track of your out-of-pocket costs, you may give us
copies of receipts for drugs that you have purchased. (If you are billed for a
covered drug, you can ask our plan to pay our share of the cost. For
instructions on how to do this, go to Chapter 5, Section 2 of this booklet.)
Here are some types of situations when you may want to give us copies of your
drug receipts to be sure we have a complete record of what you have spent for
your drugs: |
| When you purchase a covered drug at a network pharmacy at a special
price or using a discount card that is not part of our plan’s benefit. |
| When you made a copayment for drugs that are provided under a drug
manufacturer patient assistance program. |
| Any time you have purchased covered drugs at out-of-network pharmacies
or other times you have paid the full price for a covered drug under
special circumstances. |
| Check the written report we send you. Upon your
request, when you receive an Explanation of Benefits in the mail,
please look it over to be sure the information is complete and correct. If you
think something is missing from the report, or you have any questions, please
call us at COEHA Customer Service (phone numbers are on the
inside cover of this booklet). Be sure to keep these reports. They are an
important record of your drug expenses.
|
SECTION
4 During the Deductible Stage, you pay the full cost of your drugs
Section
4.1 You stay in the Deductible Stage until you have paid $150.00
for your drugs
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
2010.
| Your "full cost" is usually lower than the normal full
price of the drug, since our plan has negotiated lower costs for most drugs. |
| The "deductible" is the amount you must pay for your Part D
prescription drugs before the plan begins to pay its share. |
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.
SECTION
5 During the Initial Coverage Stage, the plan pays its share of your
drug costs and you pay your share
Section
5.1 What you pay for a drug depends on the drug and where you fill
your prescription
During the Initial Coverage Stage, the plan pays its share of
the cost of your covered prescription drugs, and you pay your share. Your share
of the cost will vary depending on the drug and where you fill your
prescription.
Your pharmacy choices
How much you pay for a drug depends on whether you get the
drug from:
| A retail pharmacy that is in the Informed RX network |
| A pharmacy that is not in the plan’s network |
| The plan’s mail-order pharmacy |
For more information about these pharmacy choices and filling
your prescriptions, see Chapter 3 in this booklet and the plan’s Pharmacy
Directory.
Section
5.2 A table that shows your costs for a 30-day and 90-day supply of a
drug
During the Initial Coverage Stage, your share of the cost of
a covered drug will be a copayment.
| "Copayment" means that you pay a fixed amount each time you
fill a prescription. |
The table below shows your share of the cost for a 30-day or
90-day supply of a covered Part D prescription drug from:
|
Type of Prescription |
Quantity |
Copayment |
|
Retail Generic Drug |
Up to a 30-day fill |
$10.00 |
|
Retail Brand Drug |
Up to a 30-day fill |
$35.00 |
|
Mail Order Generic Drug |
Up to a 90-day fill |
$25.00 |
|
Mail Order Brand Drug |
Up to a 90-day fill |
$70.00 |
For more details on filling prescriptions, see Chapter 3.
Section
5.3 You stay in the Initial Coverage Stage until your total drug
costs for the year reach $5000.00
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 the 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: |
| The $150.00 you paid when you were in the
Deductible Stage. |
| 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. |
We 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 listed on our web site
at www.coeha.com.
The Explanation of Benefits that we send to you upon
request 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
amount. 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 pay the full cost of your drugs
Section
6.1 You stay in the Coverage Gap Stage until your out-of-pocket
costs reach $4550.00
Once your total out-of-pocket costs reach $4550.00, you will
qualify for catastrophic coverage.
When you are in the Coverage Gap Stage, you pay the full
cost for your drugs. (Your full cost is usually lower than the normal full
price of the drug, since our plan has negotiated lower costs for most drugs.)
You continue paying the full cost until your yearly out-of-pocket payments reach
a maximum amount that Medicare has set. In 2010, that amount is $4550.00.
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 $4550.00,
you leave the Coverage Gap and move on to the Catastrophic Coverage Stage.
Section
6.2 How Medicare calculates your out-of-pocket costs for
prescription drugs
Here are Medicare’s rules that we must follow when we keep
track of your out-of-pocket costs for your drugs.
These payments are included in your
out-of-pocket costs
|
|
When you add up your out-of-pocket costs, you can
include the payments listed below (as long as they are
for Part D covered drugs and you followed the rules for drug coverage
that are explained in Chapter 5 of this booklet):
| The amount you pay for drugs when you are in any of the following
drug payment stages: |
| The Deductible Stage. |
| The Initial Coverage Stage. |
| The Coverage Gap Stage. |
| Any payments you made during this calendar year under another
Medicare prescription drug plan before you joined our plan. |
It matters who pays:
| If you make these payments yourself, they are included in
your out-of-pocket costs. |
| These payments are also included if they are made on your
behalf by certain other individuals or organizations. This
includes payments for your drugs made by a friend or relative, by most
charities, or by a State Pharmaceutical Assistance Program that is
qualified by Medicare. Payments made by "Extra Help" from
Medicare are also included. |
Moving on to the Catastrophic Coverage Stage:
When you (or those paying on your behalf) have spent a
total of $4550.00 in out-of-pocket costs
within the calendar year, you will move from the Coverage Gap Stage to
the
Catastrophic Coverage Stage.
|
How can you keep track of your out-of-pocket total?
| We will help you. The Explanation of Benefits report we send to
you upon request includes the current amount of your out-of-pocket costs
(Section 3 above tells about this report). When you reach a total of $4550.00
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 above tells what
you can do to help make sure that our records of what you have spent are
complete and up to date. |
SECTION
7 During the Catastrophic Coverage Stage, the plan pays most of the
cost for your drugs
Section
7.1 Once you are in the Catastrophic Coverage Stage, you will stay
in this stage for the rest of the year
You qualify for the Catastrophic Coverage Stage when your
out-of-pocket costs have reached the $4550.00 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.
| Your share of the cost for a covered drug will be either coinsurance
or a copayment, whichever is the larger amount: |
| –either – coinsurance of 5% of the cost of the drug |
| –or – $2.50 copayment for a
generic drug or a drug that is treated like a generic, or a $6.30
copayment for all other drugs. |
| Our plan pays the rest of the cost. |
SECTION
8 What you pay for vaccinations depends on how and where you get
them
Section
8.1 Our plan has separate coverage for the vaccine medication itself
and for the cost of giving you the vaccination shot
Our plan provides coverage of a number of vaccines. There are
two parts to our coverage of vaccinations:
| The first part of coverage is the cost of the vaccine medication itself.
The vaccine is a prescription medication. |
| The second part of coverage is for the cost of giving you the
vaccination shot. (This is sometimes called the
"administration" of the vaccine.) |
What do you pay for a vaccination?
What you pay for a vaccination depends on three things:
1. The type of vaccine (what you are being vaccinated
for).
| Some vaccines are considered Part D drugs. You can find these vaccines
listed in the plan’s List of Covered Drugs. |
2. Where you get the vaccine medication.
3. Who gives you the vaccination shot.
What you pay at the time you get the vaccination can vary
depending on the circumstances. For example:
| Sometimes when you get your vaccination shot, you will have to pay the
entire cost for both the vaccine medication and for getting the vaccination
shot. You can ask our plan to pay you back for our share of the cost. |
| Other times, when you get the vaccine medication or the vaccination shot,
you will pay only your share of the cost. |
To show how this works, here are three common ways you might
get a vaccination shot. Remember you are responsible for all of the costs
associated with vaccines (including their administration) during the Deductible
and Coverage Gap Stage of your benefit.
Situation 1: You buy the 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 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
the plan to pay its share of a bill you have received for medical
services or drugs). |
| You will be reimbursed the amount you paid less your normal
copayment for the vaccine (including administration) less any
difference between the amount the doctor charges and what we
normally pay. (If you are in Extra Help, we will reimburse you for
this difference.) |
Situation 3: You buy the 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 less the
amount for administering the vaccine less any difference between
the amount the doctor charges and what we normally pay. (If you
are in Extra Help, we will reimburse you for this difference.) |
Section
8.2 You may want to call us at COEHA Customer Service before you get
a vaccination
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 inside
cover of this booklet).
| We can tell you about how your vaccination is covered by our plan and
explain your share of the cost. |
| We can tell you how to keep your own cost down by using providers and
pharmacies in our network. |
| If you are not able to use a network provider and pharmacy, we can tell
you what you need to do to get payment from us for our share of the cost. |
SECTION
9 Do you have to pay the Part D "late enrollment penalty"?
Section
9.1 What is the Part D "late enrollment penalty"?
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 keep your
prescription drug coverage. The amount of the penalty depends on how long you
waited before you enrolled in drug coverage after you became eligible or how
many months after 63 days you went without drug coverage.
We will bill you for this penalty twice every year in June
and December. When you first enroll in COEHA Medicare Part D Prescription Drug
Plan, we let you know the amount of the
penalty.
Section
9.2 How much is the Part D late enrollment penalty?
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. 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 our example, let’s
say it is 14 months without coverage, which will be 14%. |
| Medicare determines the amount of the average monthly premium for Medicare
drug plans in the nation from the previous year. For 2010, this average
premium amount is $31.94. |
| You multiply together the two numbers to get your monthly penalty and
round it to the nearest 10 cents. In the example here it would be 14% times
$31.94, which equals $4.47, which rounds to $4.50. This amount would be
added to the monthly premium for someone with a late enrollment penalty. |
There are three important things to note about this monthly
premium penalty:
| First, the penalty may change each year, because the
average monthly premium can change each year. If the
national average premium (as determined by Medicare)
increases, your penalty will increase. |
| Second, you will continue to pay a penalty every month for as long
as you are enrolled in a plan that has Medicare Part D drug benefits. |
| Third, if you are under 65 and currently receiving Medicare
benefits, the late enrollment penalty will reset when you turn 65. After age
65, your late enrollment penalty will be based only on the months that you
don’t have coverage
after your initial enrollment period for Medicare. |
If you are eligible for Medicare and are under 65, any late
enrollment penalty you are paying will be eliminated when you attain age 65.
After age 65, your late enrollment penalty is based only on the months you do
not have coverage after your Age 65 Initial Enrollment Period.
Section
9.3 In some situations, you can enroll late and not have to pay the
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:
| You already have prescription drug coverage at least as good as Medicare’s
standard drug coverage. Medicare calls this "creditable drug coverage."
Creditable coverage could include drug coverage from a former employer or
union, TRICARE, or the Department of Veterans Affairs. Speak with your insurer
or your human resources
department to find out if your current drug coverage is as at least as good as
Medicare’s. |
| If you were without creditable coverage, you can avoid paying the late
enrollment penalty if you were without it for less than 63 days in a row. |
| If you didn’t receive enough information to know whether or not your
previous drug coverage was creditable. |
| You lived in an area affected by Hurricane Katrina at the time of the
hurricane (August 2005) – and – you signed up for a Medicare
prescription drug plan by December 31, 2006 – and – you have stayed
in a Medicare prescription drug plan. |
| You are receiving Extra Help from Medicare. |
Section
9.4 What can you do if you disagree about your late enrollment
penalty?
If you disagree about your late enrollment penalty,
you can ask us to review the decision about your 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.
SECTION 1
Situations in which you should ask our plan to pay our share of the cost of your
covered drugs
Section
1.1 If you pay our plan’s share of the cost of your covered drugs,
you can ask us for payment
Sometimes when you get a prescription drug, you may need to
pay the 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). Asking for reimbursement in the first three
examples below are types of coverage decisions (for more information about
coverage decisions, go to Chapter 7 of this booklet).
Here are examples of situations in which you may need to ask
our plan to pay you back:
1. When you use an out-of-network pharmacy (under emergency
circumstances) to get a prescription fille
If you go to an out-of-network pharmacy under emergency
circumstances, which would not permit access to an Informed Rx 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 Informed RX. 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 a network 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. |
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 9 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.
SECTION
2 How to ask us to pay you back
Section
2.1 How and where to send us your
request for payment
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. Upon receipt of your documents, we will handle the
necessary paperwork and file the claim with Informed RX.
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
Please be sure to contact COEHA Customer Service if you have
any questions. If you don’t know what you owe, 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.
SECTION
3 We will consider your request for payment and say yes or no
Section
3.1 We check to see whether we should cover the drug and how much we
owe
When we receive your request for payment, we will let you
know if we need any additional information from you. Otherwise, we will consider
your request and decide whether to pay it and how much we owe.
| If we decide that the drug is covered and you followed all the rules for
getting the drug, we will pay for our share of the cost. Informed RX will
mail your reimbursement of all but your share to you. (Chapter 3 explains
the rules you need to follow for getting your Part D prescription drugs.) |
| If we decide that the drug is not covered, or you did not
follow all the rules, we will not pay for our share of the cost. Instead, we
will send you a letter that explains the reasons why we are not sending the
payment you have requested and your rights to appeal that decision. |
Section
3.2 If we tell you that we will not pay for the drug, you can make
an appeal
If you think we have made a mistake in turning you down, 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:
| When you use an out-of-network pharmacy to get a prescription filled |
| When you pay the full cost for a prescription because you don’t have
your plan membership card with you |
| When you pay the full cost for a prescription in other situations |
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 legal 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."
Then after you have read Section 4, you can go to Section 5 in Chapter 7 for a
step-by-step explanation of how to file an appeal.
SECTION
4 Other situations in which you should save your receipts and send
them to the plan
Section
4.1 In some cases, you should send your receipts to the plan to help
us track your out-of-pocket drug costs
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 Informed RX 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 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 the
plan’s price
Sometimes when you are in the Deductible and Coverage Gap
Stage you can buy your drug at a network pharmacy for a price that is
lower than the plan’s price.
| For example, a pharmacy might offer a special price on the drug, or you
may have a discount card that is outside the plan’s benefit that offers
a lower price. |
| Unless special conditions apply, you must use a network pharmacy in
these situations and your drug must be on our Drug List. |
| Save your receipt and send a copy to us so that we can have your
out-of-pocket expenses count toward qualifying you for the Catastrophic
Coverage Stage. |
| Please note: If you are in either the Deductible or Coverage Gap
Stage, the plan will not pay for any share of these drug costs. But sending
the receipt allows
Informed RX to calculate 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 have 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. But sending the receipt allows
Informed RX to calculate 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.
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,
disability, religion, sex, health, ethnicity, creed (beliefs), age, or national
origin.
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 inside cover
of this booklet). If you have a complaint, such as a problem with wheelchair
access, COEHA Customer Service can help.
Section
1.2 We must ensure that you get timely access to your covered drugs
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 of this booklet tells what you can
do.
Section
1.3 We must protect the privacy of your personal health information
Federal and state laws protect the privacy of your medical
records and personal health information. We protect your personal health
information as required by these laws.
| Your "personal health information" includes the personal
information you gave us when you enrolled in this plan as well as your
medical records and other medical and health information. |
| The laws that protect your privacy give you rights related to getting
information and controlling how your health information is used. We give you
a written notice, called a
"Notice of Privacy Practice", that tells about these rights and
explains how we protect the privacy of your health
information. |
How do we protect the privacy of your health information?
| We make sure that unauthorized people don’t see or change your records. |
| In most situations, if we give your health information to anyone who isn’t
providing your care or paying for your care, we are required to get written
permission from you first. Written permission can be given by you or by
someone you have given legal power to make decisions for you. |
| There are certain exceptions that do not require us to get your written
permission first. These exceptions are allowed or required by law. |
| For example, we are required to release health
information to government agencies that are checking on quality of care. |
| Because you are a member of our plan through Medicare, we are required to
give Medicare your health information including information about your Part
D prescription drugs. If Medicare releases your information for research or
other uses, this will be done according to Federal statutes and regulations. |
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 consider your request and 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 inside cover of this booklet).
Section
1.4 We must give you information about the plan, the Informed RX
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. If you want any of the following kinds of
information, please call COEHA Customer Service (phone numbers are on the inside
cover of this booklet):
| Information about our plan. This
includes, for example, information about the plan’s financial condition. It
also includes information about the number of appeals made by members and how
it compares to other Medicare prescription drug plans. |
| Information about the Informed RX network pharmacies. |
| For example, you have the right to get information from us or Informed RX
about the pharmacies in the
Informed RX network. |
| For a list of the pharmacies in the Informed RX network, see the Pharmacy
Directory. |
| For more detailed information about the Informed RX pharmacies, you can
call Informed RX Customer Service at 1-866-443-1095 or visit their website
at https://informedrx.rxportal.sxc.com/rxclaim/portal/preLogin. |
| Information about your coverage and rules you must follow in using your
coverage. |
| To get the details on your Part D prescription drug coverage, see Chapters
3 and 4 of this booklet plus the plan’s List of Covered Drugs
(Formulary). These chapters, together with the List of Covered Drugs,
tell you what drugs are covered and explain the rules you must follow and
the restrictions to your coverage for certain drugs. |
| If you have questions about the rules or restrictions, please call COEHA
Customer Service (phone numbers are on the inside cover of this booklet). |
| Information about why something is not covered and what you can do about
it. |
| If a Part D drug is not covered for you, or if your coverage is
restricted in some way, you can ask us for a written explanation. You have
the right to this explanation even if you received the drug from an
out-of-network pharmacy. |
| If you are not happy or if you disagree with a decision we make about
what Part D drug is covered for you, you have the right to ask us to
change the decision. For details on what to do if something is not covered
for you in the way you think it should be covered, see Chapter 7 of this
booklet. It gives you the details about how to ask the plan for a decision
about your coverage and how to make an appeal if you want us to change our
decision. (Chapter 7 also tells about how to make a complaint about
quality of care, waiting times, and other concerns.) |
| If you want to ask our plan to pay our share of the cost for a Part D
prescription drug, see Chapter 5 of this booklet. |
Section
1.5 We must support your right to make decisions about your care
You have the right to give instructions about what is to be
done if you are not able to make medical decisions for yourself
Sometimes people become unable to make health care decisions
for themselves due to accidents or serious illness. You have the right to say
what you want to happen if you are in this situation. This means that, if you
want to, you can:
| Fill out a written form to give someone the legal authority to make
medical decisions for you if you ever become unable to make decisions
for yourself. |
| Give your doctors written instructions about how you want them to
handle your medical care if you become
unable to make decisions for yourself. |
The legal documents that you can use to give your directions
in advance in these situations are called "advance directives."
There are different types of advance directives and different names for them.
Documents called "living will" and "power of attorney
for health care" are examples of advance directives.
If you want to use an "advance directive" to give
your instructions, here is what to do:
| Get the form. If you want to have an advance directive, you can get a
form from your lawyer, from a social worker, or from some office supply
stores. You can sometimes get advance directive forms from organizations that
give people information about Medicare. You can also contact COEHA Customer
Service to ask for the forms (phone numbers are on the inside cover of this
booklet). |
| Fill it out and sign it. Regardless of where you get this form, keep
in mind that it is a legal document. You should consider having a lawyer help
you prepare it. |
| Give copies to appropriate people. You should give a copy of the form
to your doctor and to the person you name on the form as the one to make
decisions for you if you can’t. You may want to give copies to close friends
or family members as well. Be sure to keep a copy at home. |
If you know ahead of time that you are going to be
hospitalized, and you have signed an advance directive, take a copy with you
to the hospital.
| If you are admitted to the hospital, they will ask you whether you have
signed an advance directive form and whether you have it with you. |
| If you have not signed an advance directive form, the hospital has forms
available and will ask if you want to sign one. |
Remember, it is your choice whether you want to fill out an
advance directive (including whether you want to sign one if you are in the
hospital). According to law, no one can deny you care or discriminate against
you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that
a doctor or hospital 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. What-ever 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 inside cover of this booklet).
Section
1.7 What can you do if you think you are being treated unfairly or
your rights are not being respected?
If it is about discrimination, call the Office for Civil
Rights
If you think you have been treated unfairly or your rights
have not been respected due to your race, disability, religion, sex, health,
ethnicity, creed (beliefs), age, or national origin, you should call the
Department of Health and Human Services’ Office for Civil Rights at
1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil
Rights.
Is it about something else?
If you think you have been treated unfairly or your rights
have not been respected, and it’s not about discrimination, you
can get help dealing with the problem you are having:
| You can call COEHA Customer Service (phone numbers are on the
inside cover of this booklet). |
| You can call the State Health Insurance Assistance Program. For
details about this organization and how to contact it, go to Chapter 2,
Section 3. |
Section
1.8 How to get more information about your rights
There are several places where you can get more information
about your rights:
| You can call COEHA Customer Service (phone numbers are on the
inside cover of this booklet). |
| You can call the State Health Insurance Assistance Program. For
details about this organization and how to contact it, go to Chapter 2,
Section 3. |
| You can contact Medicare. |
| You can visit the Medicare website (http://www.medicare.gov) to read or
download the publication "Your Medicare Rights &
Protections." |
| You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048. |
SECTION
2 You have some responsibilities as a member of the plan
Section
2.1 What are your responsibilities?
Things you need to do as a member of the plan are listed
below. If you have any questions, please call COEHA Customer Service (phone
numbers are on the inside cover of this booklet). We’re here to help.
| Get familiar with your covered drugs and the rules you must follow to get
these covered drugs. Use this Evidence
of Coverage booklet to learn what is covered for you and the rules you need
to follow to get your covered drugs. |
| Chapters 3 and 4 give the details about your coverage for Part D
prescription drugs. |
| If you have any other prescription drug coverage besides our plan, you are
required to tell us. Please call
COEHA Customer Service to let us know. |
| We are required to follow rules set by Medicare to make sure that you are
using all of your coverage in combination when you get your covered drugs
from our plan. This is called "coordination of benefits"
because it involves coordinating the drug benefits you get from our plan
with any other drug benefits available to you. We’ll help you with it. |
| Tell your doctor and pharmacist that you are enrolled in our plan.
Show your plan membership card whenever you get your Part D
prescription drugs. |
| Help your doctors and other providers help you by giving them information,
asking questions, and following through on your care. |
| To help your doctors and other health providers give you the best care,
learn as much as you are able to about your health problems and give them
the
information they need about you and your health. Follow the treatment plans
and instructions that you and your doctors agree upon. |
| If you have any questions, be sure to ask. Your doctors and other health
care providers are supposed to explain things in a way you can understand.
If you ask a question and you don’t understand the answer you are given,
ask again. |
| Pay what you owe. As a plan
member, you are
responsible for these payments: |
| You must pay your plan premiums to continue
being a member of our plan. |
| For some of your drugs covered by the plan, you must pay your share of the
cost when you get the drug. This will be a copayment (a fixed amount).
Chapter 4 tells what you must pay for your Part D prescription drugs. |
| If you get any drugs that are not covered by our plan or by other
insurance you may have, you must pay the full cost. |
| Tell us if you move. If you
are going to move, it’s
important to tell us right away. Call COEHA Customer Service (phone numbers
are on the inside cover of this booklet). |
| We need to keep your membership record up to date and know how to contact
you. |
| Call COEHA Customer Service for help if you have questions or concerns.
We also welcome any suggestions you may have for improving our
plan. |
| Phone numbers for COEHA Customer Service are on the inside cover of this
booklet. |
| For more information on how to reach us, including our mailing address,
please see Chapter 2. |
SECTION 1 Introduction
Section 1.1 What to do if
you have a problem or concern
Please call us first
Your health and satisfaction are important to us. When you
have a problem or concern, we hope you’ll try an informal approach first:
Please call COEHA Customer Service (phone numbers are on the front inside cover
of this booklet). We will work with you to try and find a satisfactory solution
to your problem.
You have rights as a member of our plan and as someone who is
getting Medicare. We pledge to honor your rights, to take your problems and
concerns seriously, and to treat you with respect.
Two formal processes for dealing with problems
Sometimes you might need a formal process for dealing with a
problem you are having as a member of our plan.
This chapter explains two types of formal processes for
handling problems:
| For some types of problems, you need to use the process for coverage
decisions and making appeals. |
| For other types of problems you need to use the process for making
complaints. |
Both of these processes have been approved by Medicare. To
ensure fairness and prompt handling of your problems, each process has a set of
rules, procedures, and deadlines that must be followed by us and by you.
Which one do you use? That depends on the type of problem you
are having. The guide in Section 3 will help you identify the right process to
use.
Section 1.2 What about the
legal terms?
There are technical legal terms for some of the rules,
procedures, and types of deadlines explained in this chapter. Many of these
terms are unfamiliar to most people and can be hard to understand.
To keep things simple, this chapter explains the legal rules
and procedures using more common words in place of certain legal terms. For
example, this chapter generally says "making a complaint" rather than
"filing a grievance," "coverage decision" rather than
"coverage determination," and "Independent Review
Organization" instead of "Independent Review Entity." It also
uses
abbreviations as little as possible.
It can be helpful – and sometimes quite important – for
you to know the correct legal terms for the situation you are in. Knowing which
terms to use will help you communicate more clearly and accurately when you are
dealing with your problem and get the right help or information for your
situation. To help you know which terms to use, we include legal terms when we
give the
details for handling specific types of situations.
SECTION 2 You can get help
from government organizations that are not connected with us
Section 2.1 Where to get
more information and personalized assistance
Sometimes it can be confusing to start or follow through the
process for dealing with a problem. This can be especially true if you do not
feel well or have limited energy. Other times, you may not have the knowledge
you need to take the next step. Perhaps both are true for you.
Get help from an independent government organization
We are always available to help you. But in some situations
you may also want help or guidance from someone who is not connected to us. You
can always contact your State Health Insurance Assistance Program. This
government program has trained counselors in every state. The program is not
connected with our plan or with any insurance company or health plan. The
counselors at this program can help you understand which process you should use
to handle a problem you are having. They can also answer your questions, give
you more information, and offer guidance on what to do.
Their services are free. You will find more information on
State Health Insurance Assistance Programs in Chapter 2, Section 3 of this
booklet.
You can also get help and information from Medicare
For more information and help in handling a problem, you can
also contact Medicare. Here are two ways to get information
directly from Medicare:
| You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a
week. TTY users should call
1-877-486-2048. |
| You can visit the Medicare website (http://www.medicare.gov). |
SECTION 3 To deal with your
problem, which process should you use?
Section 3.1 Should you use
the process for coverage decisions and appeals or should you use the
process for making complaints?
If you have a problem or concern and you want to do something
about it, you don’t need to read this whole chapter. You just need to find and
read the parts of this chapter that apply to your situation. The guide that
follows will help.
To figure out which part of this chapter tells what to do for
your problem or concern, START HERE:
|
Is your problem or concern about your benefits and
coverage?
(This includes problems about whether particular
prescription drugs are covered or not, the way in which they are covered,
and problems related to payment for prescription drugs.)
| If your answer is YES, go on to the next section of this
chapter, Section 4: A guide to the basics of coverage decisions and
making appeals |
| If your answer is NO, skip ahead to Section 7 at the end of
this chapter: How to make a complaint about quality of care,
waiting times, customer service or other concerns
|
|
COVERAGE DECISIONS AND APPEALS
SECTION 4 A guide to the
basics of coverage decisions and appeals
Section 4.1 Asking for
coverage decisions and making appeals: the big picture
The process for coverage decisions and making appeals deals
with problems related to your benefits and coverage for prescription drugs,
including problems related to payment. This is the process you use for issues
such as whether a drug is covered or not and the way in which the drug is
covered.
Asking for coverage decisions
A coverage decision is a decision we make about your benefits
and coverage or about the amount we will pay for your prescription drugs. We
make a coverage decision for you whenever you fill a prescription at a pharmacy.
We are making a coverage decision for you whenever we decide
what is covered for you and how much we pay:
| Usually, there is no problem. We decide the drug is covered and pay our
share of the cost. |
| But in some cases we might decide the drug is not covered or is no longer
covered by Medicare for you. If you disagree with this coverage decision,
you can make an appeal. |
Making an appeal
If we make a coverage decision and you are not satisfied with
this decision, you can "appeal" the decision. An appeal is a formal
way of asking us to review and change a coverage decision we have made.
When you make an appeal we review the coverage decision we
have made to check to see if we were being fair and following all of the rules
properly. When we have completed the review we give you our decision.
If we say no to all or part of your Level 1 Appeal, you
can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an
independent organization that is not connected to our plan. If you are not
satisfied with the decision at the Level 2 Appeal, you may be able to continue
through several more levels of appeal.
Section 4.2 How to get help
when you are asking for a coverage decision or making an appeal
Would you like some help? Here are resources you may wish to
use if you decide to ask for any kind of coverage decision or
appeal a decision:
| You can call us at COEHA Customer Service (phone numbers are on the
front inside cover). |
| To get free help from an independent organization that is not
connected with our plan, contact your State Health Insurance Assistance
Program (see Section 2 of this chapter). |
| You should consider getting your doctor or other
prescriber involved if possible, especially if you want a "fast"
or "expedited" decision. In most situations
involving a coverage decision or appeal, your doctor or other prescriber must
explain the medical reasons that support your request. Your doctor or
other prescriber can’t
request every appeal. He/she can request a coverage decision and a Level 1
Appeal with the plan. To request any appeal after Level 1, your doctor or
other prescriber must be appointed as your "representative" (see
below about "representatives"). |
| You can ask someone to act on your behalf. If you want to, you can
name another person to act for you as your "representative" to ask
for a coverage decision or make an appeal. |
| There may be someone who is already legally
authorized to act as your representative under State law. |
| If you want a friend, relative, your doctor or other prescriber, or
other person to be your representative, call COEHA Customer Service to
learn how to name your appointed representative. You and the person you
want as your appointed representative must sign and date a statement that
gives the person legal permission to be your appointed representative. You
must give our plan a copy of the signed form. |
| You also have the right to hire a lawyer to act for you. You may
contact your own lawyer, or get the name of a lawyer from your local bar
association or other
referral service. There are also groups that will give you free legal services
if you qualify. However, you are not required to hire a lawyer to ask
for any kind of coverage decision or appeal a decision. |
SECTION
5 Your Part D prescription drugs: How to ask for a coverage decision
or make an appeal
|
? |
Have you read Section 4 of this chapter (A guide to
"the basics" of coverage decisions and appeals)? If not, you
may want to read it before you start this section. |
Section
5.1 This section tells you what to do if you have problems getting a
Part D drug or you want us to pay you back for a Part D drug
Your benefits as a member of our plan include coverage for
many outpatient prescription drugs. Medicare calls these outpatient prescription
drugs "Part D drugs." You can get these drugs as long as they are
included in our plan’s List of Covered Drugs (Formulary) and they are
medically necessary for you, as determined by your primary care doctor or other
provider.
| This section is about your Part D drugs only. To keep things simple,
we generally say "drug" in the rest of this section, instead of
repeating "covered outpatient prescription drug" or "Part D
drug" every time. |
| For details about what we mean by Part D drugs, the List of Covered
Drugs, rules and restrictions on coverage, and cost information, see
Chapter 5 (Using our plan’s coverage for your Part D prescription drugs)
and Chapter 6 (What you pay for your Part D prescription drugs). |
Part D coverage decisions and appeals
As discussed in Section 4 of this chapter, a coverage
decision is a decision we make about your benefits and coverage or about the
amount we will pay for your drugs.
|
Legal
Terms |
A coverage decision is often called an "initial
determination" or "initial decision." When the coverage
decision is about your Part D drugs, the initial determination is called a
"coverage determination." |
Here are examples of coverage decisions you ask us to make
about your Part D drugs:
| You ask us to make an exception, including: |
| Asking us to cover a Part D drug that is not on the plan’s List of
Covered Drugs |
| Asking us to waive a restriction on the plan’s
coverage for a drug (such as limits on the amount of the drug you can get) |
| You ask us whether a drug is covered for you and whether you satisfy any
applicable coverage rules. (For example, when your drug is on the plan’s List
of Covered Drugs but we require you to get approval from us before we
will
cover it for you.) |
| You ask us to pay for a prescription drug you already bought. This is a
request for a coverage decision about payment. |
If you disagree with a coverage decision we have made, you
can appeal our decision.
This section tells you both how to ask for coverage decisions
and how to request an appeal. Use this guide to help you determine which part
has information for your situation:
Which of these situations are you in?
|
Request a Coverage Decision:
Q.
Do you want to ask us to make an exception to
the rules or
restrictions on our plan’s coverage of a drug?
A. You can ask us to make an exception. (This is a
type of coverage decision.) Start with Section 5.2 of this chapter.
Q. Do you want to ask us to cover a drug for you?
(For example, if we cover the drug but we require you to get approval from
us first.)
A. You can ask us for a coverage decision. Skip
ahead to Section 5.4 of this chapter.
Q. Do you want to ask us to pay you back for a drug
you have
already received and paid for?
A. You can ask us to pay you back. (This is a type
of coverage decision.) Skip ahead to Section 5.4 of this chapter.
|
|
Make an Appeal:
Q. Has our plan already told you that we will not
cover or pay for a drug in the way that you want it to be covered or paid
for?
A. You can make an appeal. (This means you are asking
us to
reconsider.) Skip ahead to Section 5.5 of this chapter. |
Section
5.2 What is an exception?
If a drug is not covered in the way you would like it to be
covered, you can ask the plan to make an "exception." An exception is
a type of coverage decision. Similar to other types of coverage decisions, if we
turn down your request for an exception, you can
appeal our decision.
When you ask for an exception, your doctor or other
prescriber will need to explain the medical reasons why you need the exception
approved. We will then consider your request. Here are two
examples of exceptions that you or your doctor or other prescriber can
ask us to make:
- Covering a Part D drug for you that is not on our plan’s List of
Covered Drugs (Formulary).
(We call it the "Drug List" for
short.)
|
Legal
Terms |
Asking for coverage of a drug that is not on the Drug List
is sometimes called asking for a "formulary
exception." |
| If we agree to make an exception and cover a drug that is not on the
Drug List, you will need to pay the cost-sharing amount that applies to
all of our drugs. You cannot ask for an exception to the copayment
amount we require you to pay for the drug. |
| You cannot ask for coverage of any "excluded drugs" or other
non-Part D drugs which Medicare does not cover. (For more information
about excluded drugs, see Chapter 5.) |
- Removing a restriction on the plan’s coverage for a covered drug
.
There are extra rules or restrictions that apply to certain drugs on the plan’s
List of Covered Drugs (for more information, go to Chapter 3).
|
Legal
Terms |
Asking for removal of a restriction on coverage for a
drug is sometimes called asking for a "formulary exception." |
| The extra rules and restrictions on coverage for certain drugs include: |
 | Being required to use the generic version of a drug instead of the
brand-name drug. |
| Getting plan approval in advance before we will agree to cover the
drug for you. (This is sometimes called "prior authorization.") |
| Being required to try a different drug first
before we will agree to cover the drug you are asking for. (This is
sometimes called "step
therapy.") |
| Quantity limits. For some drugs, there are
restrictions on the amount of the drug you can have. |
| If our plan agrees to make an exception and waive a
restriction for you, you can ask for an exception to the copayment amount
we require you to pay for the drug. |
Section
5.3 Important things to know about asking for exceptions
Your doctor must tell us the medical reasons
Your doctor or other prescriber must give us a written
statement that explains the medical reasons for requesting an exception. For a
faster decision, include this medical information from your doctor or other
prescriber when you ask for the exception.
Typically, our Drug List includes more than one drug for
treating a particular condition. These different possibilities are called
"alternative" drugs. If an alternative drug would be just as effective
as the drug you are requesting and would not cause more side effects or other
health problems, we will generally not approve your
request for an exception.
Our plan can say yes or no to your request
| If we approve your request for an exception, our approval usually is valid
until the end of the plan year. This is true as long as your doctor continues
to prescribe the drug for you and that drug continues to be safe and effective
for treating your condition. |
| If we say no to your request for an exception, you can ask for a review of
our decision by making an appeal. Section 5.5 tells you how to make an appeal
if we say no. |
The next section tells you how to ask for a coverage
decision,
including an exception.
Section
5.4 Step-by-step: How to ask for a coverage decision, including
an exception
Step 1: You ask our plan to make a coverage decision
about the drug(s) or payment you need . If your
health
requires a quick response, you must ask us to make a "fast
decision." You cannot ask for a fast decision if you are asking us to pay
you back for a drug you already bought.
What to do
| Request the type of coverage decision you want. Start by calling,
writing, or faxing our plan to make your request. You, your representative, or
your doctor (or other prescriber) can do this. For the details, go to Chapter
2, Section 1 and look for the section called, How to contact our plan when
you are asking for a coverage decision about your Part D prescription drugs.
Or if you are asking us to pay you back for a drug, go to the section called, Where
to send a request that asks us to pay for our share of the cost for medical
care or a drug you have received. |
| You or your doctor or someone else who is acting on your behalf can
ask for a coverage decision. Section 4 of this chapter tells how you can give
written permission to someone else to act as your representative. You can also
have a lawyer act on your behalf. |
| If you want to ask our plan to pay you back for a drug, start by
reading Chapter 7 of this booklet:
Asking the plan to pay its share of a bill you have
received for medical services or drugs. Chapter 7
describes the situations in which you may need to ask for reimbursement. It
also tells how to send us the paperwork that asks us to pay you back for our
share of the cost of a drug you have paid for. |
| If you are requesting an exception, provide the "doctor’s
statement." Your doctor or other prescriber must give us the
medical reasons for the drug exception you are requesting. (We call this the
"doctor’s statement.") Your doctor or other prescriber can fax or
mail the statement to our plan. Your doctor or other prescriber can tell us on
the phone and follow up by faxing or mailing the signed statement. See
Sections 5.2 and 5.3 for more information about
exception requests. |
If your health requires it, ask us to give you a "fast
decision"
|
Legal
Terms |
A "fast decision" is called an "expedited
decision." |
| When we give you our decision, we will use the "standard"
deadlines unless we have agreed to use the "fast" deadlines. A
standard decision means we will give you an answer within 72 hours after
we
receive your doctor’s statement. A fast decision means we will answer
within 24 hours. |
| To get a fast decision, you must meet two
requirements: |
| You can get a fast decision only if you are asking for a drug you have
not yet received. (You cannot get a fast decision if you are asking us
to pay you back for a drug you have already bought.) |
| You can get a fast decision only if using the standard deadlines
could cause serious harm to your health or hurt your ability to function. |
| If your doctor or other prescriber tells us that your health requires a
"fast decision," we will
automatically agree to give you a fast decision. |
| If you ask for a fast decision on your own (without your doctor’s or
other prescriber’s support), our plan will
decide whether your health requires that we give you a fast decision. |
| If we decide that your medical condition does not meet the requirements
for a fast decision, we will send you a letter that says so (and we will
use the standard deadlines instead). |
| This letter will tell you that if your doctor or
other prescriber asks for the fast decision, we will automatically give a
fast decision. |
| The letter will also tell how you can file a
complaint about our decision to give you a standard decision instead of
the fast decision you
requested. It tells how to file a "fast" complaint, which means
you would get our answer to your complaint within 24 hours. (The process
for making a complaint is different from the process for coverage
decisions and appeals. For more
information about the process for making complaints, see Section 7 of this
chapter.) |
Step 2: Our plan considers your
request and we give you our answer.
Deadlines for a "fast" coverage decision
| If we are using the fast deadlines, we must give you our answer within 24
hours. |
| Generally, this means within 24 hours after we
receive your request. If you are requesting an
exception, we will give you our answer within 24 hours after we receive your
doctor’s statement supporting your request. We will give you our
answer sooner if your health requires us to. |
| If we do not meet this deadline, we are required to send your request on
to Level 2 of the appeals process, where it will be reviewed by an
independent outside organization. Later in this section, we tell about this
review organization and explain what happens at Appeal Level 2. |
| If our answer is yes to part or all of what you
requested, we must provide the coverage we have agreed to provide within
24 hours after we receive your request or doctor’s statement supporting your
request. |
| If our answer is no to part or all of what you
requested, we will send you a written statement that explains why we said
no. |
Deadlines for a "standard" coverage decision
| If we are using the standard deadlines, we must give you our answer within
72 hours. |
| Generally, this means within 72 hours after we receive your request. If
you are requesting an exception, we will give you our answer within 72 hours
after we receive your doctor’s statement supporting your request. We will
give you our answer sooner if your health requires us to. |
| If we do not meet this deadline, we are required to send your request on
to Level 2 of the appeals process, where it will be reviewed by an
independent organization. Later in this section, we tell about this review
organization and explain what happens at Appeal Level 2. |
| If our answer is yes to part or all of what you
requested – |
| If we approve your request for coverage, we must provide the coverage
we have agreed to provide within 72 hours after we receive your
request or doctor’s statement supporting your request. |
| If we approve your request to pay you back for a drug you already
bought, we are also required to send payment to you within 30
calendar days after we receive your request or doctor’s statement
supporting your request. |
| If our answer is no to part or all of what you
requested, we will send you a written statement that explains why we
said no. |
Step 3: If we say no to your
coverage request, you
decide if you want to make an appeal.
| If our plan says no, you have the right to request an
appeal. Requesting an appeal means asking us to reconsider – and possibly
change – the decision we made. |
Section
5.5 Step-by-step: How to make a Level 1 Appeal
(how to
ask for a review of a coverage decision made by our plan)
|
Legal
Terms |
When you start the appeals process by making an appeal, it
is called the "first level of appeal" or a "Level 1
Appeal."
An appeal to the plan about a Part D drug coverage
decision is called a plan "redetermination." |
Step 1: You contact our plan and
make your Level 1
Appeal. If your health requires a quick response,
you must ask for a "fast appeal."
What to do
| To start your appeal, you (or your representative or your doctor or other
prescriber) must contact our plan. |
| For details on how to reach us by phone, fax, mail, or in person for any
purpose related to your appeal, go to Chapter 2, Section 1, and look for the
section called, How to contact our plan when you are making an appeal
about your Part D prescription drugs. |
| Make your appeal in writing by submitting a signed request. You may also
ask for an appeal by calling us at the phone number shown in Chapter 2, Section
1, (How to contact our plan when you are making an appeal about your Part D
prescription drugs). |
| You must make your appeal request within 60
calendar days from the date on the written notice we sent to tell you our
answer to your request for a coverage decision. If you miss this deadline and
have a good reason for missing it, we may give you more time to make your
appeal. |
| You can ask for a copy of the information in your appeal and add more
information. |
| You have the right to ask us for a copy of the information regarding your
appeal. We are
allowed to charge a fee for copying and sending this information to you. |
| If you wish, you and your doctor or other
prescriber may give us additional information to support your appeal. |
If your health requires it, ask for a "fast appeal"
|
Legal
Terms |
A "fast appeal" is also called an
"expedited appeal." |
| If you are appealing a decision our plan made about a drug you have not
yet received, you and your doctor or other prescriber will need to decide
if you need a "fast appeal." |
| The requirements for getting a "fast appeal" are the same as
those for getting a "fast decision" in
Section 5.4 of this chapter. |
Step 2: Our plan considers your
appeal and we give you our answer.
| When our plan is reviewing your appeal, we take another careful look at
all of the information about your coverage request. We check to see if we
were being fair and
following all the rules when we said no to your request. We may contact you
or your doctor or other prescriber to get more information. |
Deadlines for a "fast" appeal
| If we are using the fast deadlines, we must give you our answer within 72
hours after we receive your appeal. We will give you our answer sooner if
your health
requires it. |
| If we do not give you an answer within 72 hours, we are required to send
your request on to Level 2 of the appeals process, where it will be reviewed
by an Independent Review Organization. (Later in this section, we tell about
this review organization and explain what happens at Level 2 of the
appeals process.) |
| If our answer is yes to part or all of what you
requested, we must provide the coverage we have agreed to provide
within 72 hours. |
| If our answer is no to part or all of what you
requested, we will send you a written statement that explains why we
said no and how to appeal our
decision. |
Deadlines for a "standard" appeal
| If we are using the standard deadlines, we must give you our answer within
7 calendar days after we
receive your appeal. We will give you our decision sooner if you have not
received the drug yet and your health condition requires us to do so. |
| If we do not give you a decision within 7 calendar days, we are required
to send your request on to Level 2 of the appeals process, where it will be
reviewed by an Independent Review Organization. Later in this section, we
tell about this
review organization and explain what happens at Level 2 of the appeals
process. |
| If our answer is yes to part or all of what you
requested – |
| If we approve a request for coverage, we must provide the coverage we
have agreed to provide as quickly as your health requires, but no later
than 7 calendar days after we receive your
appeal. |
| If we approve a request to pay you back for a drug you already bought, we
are required to send payment to you within 30 calendar days after
we receive your appeal request. |
| If our answer is no to part or all of what you
requested, we will send you a written statement that
explains why we said no and how to appeal our
decision. |
Step 3: If we say no to your
appeal, you decide if you want to continue with the appeals process and make another
appeal.
| If our plan says no to your appeal, you then choose whether to accept this
decision or continue by making another appeal. |
| If you decide to make another appeal, it means your
appeal is going on to Level 2 of the appeals process (see below). |
Section
5.6 Step-by-step: How to make a Level 2 Appeal
If our plan says no to your appeal, you then choose whether
to
accept this decision or continue by making another appeal. If you decide to go
on to a Level 2 Appeal, the Independent Review
Organization reviews the decision our plan made when we said no to your
first appeal. This organization decides whether the decision we made should be
changed.
|
Legal
Terms |
The formal name for the "Independent
Review Organization" is the "Independent Review Entity."
It is sometimes called the "IRE." |
Step 1: To make a Level 2 Appeal,
you must contact the Independent Review Organization and ask for a review of
your case.
| If our plan says no to your Level 1 Appeal, the written notice we send you
will include instructions on how to make a Level 2 Appeal with the
Independent Review Organization. These instructions will tell who can make
this Level 2 Appeal, what deadlines you must follow, and how to reach the
review organization. |
| When you make an appeal to the Independent Review Organization, we will
send the information we have about your appeal to this organization. This
information is called your "case file." You have the right to
ask us for a copy of your case file. We are allowed to charge you a fee
for copying and sending this information to you. |
| You have a right to give the Independent Review
Organization additional information to support your
appeal. |
Step 2: The Independent Review
Organization does a
review of your appeal and gives you an answer.
| The Independent Review Organization is an outside, independent
organization that is hired by Medicare. This organization is not
connected with our plan and it is not a government agency. This organization
is a company chosen by Medicare to review our decisions about your Part D
benefits with our plan. |
| Reviewers at the Independent Review Organization will take a careful look
at all of the information related to your appeal. The organization will tell
you its decision in writing and explain the reasons for it. |
Deadlines for "fast" appeal at Level 2
| If your health requires it, ask the Independent Review Organization for a
"fast appeal." |
| If the review organization agrees to give you a "fast
appeal," the review organization must give you an
answer to your Level 2 Appeal within 72 hours after it receives your
appeal request. |
| If the Independent Review Organization says yes to part or all of what you
requested, we must provide the drug coverage that was approved by the
review
organization within 24 hours after we receive the
decision from the review organization. |
Deadlines for "standard" appeal at Level 2
| If you have a standard appeal at Level 2, the review
organization must give you an answer to your Level 2 Appeal within 7
calendar days after it receives your appeal. |
| If the Independent Review Organization says yes to part or all of what you
requested – |
| If the Independent Review Organization approves a request for coverage, we
must provide the drug coverage that was approved by the review
organization within 72 hours after we receive the
decision from the review organization. |
| If the Independent Review Organization approves a request to pay you back
for a drug you already bought, we are required to send payment to you
within 30 calendar days after we receive the
decision from the review organization. |
What if the review organization says no to your appeal?
If this organization says no to your appeal, it means the
organization agrees with our decision not to approve your request. (This is
called "upholding the decision." It is also called "turning down
your appeal.")
To continue and make another appeal at Level 3, the dollar
value of the drug coverage you are requesting must meet a minimum amount. If the
dollar value of the coverage you are requesting is too low, you cannot make
another appeal and the decision at Level 2 is final. The notice you get from the
Independent Review Organization will tell you if the dollar value of the
coverage you are
requesting is high enough to continue with the appeals process.
Step 3: If the dollar value of
the coverage you are
requesting meets the requirement, you choose whether you want to take your
appeal further.
| There are three additional levels in the appeals process after Level 2
(for a total of five levels of appeal). |
| If your Level 2 Appeal is turned down and you meet the requirements to
continue with the appeals process, you must decide whether you want to go on
to Level 3 and make a third appeal. If you decide to make a third
appeal, the details on how to do this are in the written notice you got
after your second appeal. |
| The Level 3 Appeal is handled by an administrative law judge. Section 6 in
this chapter tells more about Levels 3, 4, and 5 of the appeals process. |
SECTION 6 Taking your appeal to Level
3 and beyond
Section 6.1 Levels of
Appeal 3, 4, and 5 for Part D Drug Appeals
This section may be appropriate for you if you have made a
Level 1 Appeal and a Level 2 Appeal, and both of your appeals have been turned
down.
If the dollar value of the drug you have appealed meets
certain minimum levels, you may be able to go on to additional levels of appeal.
If the dollar value is less than the minimum level, you cannot appeal any
further. If the dollar value is high enough, the written response you receive to
your Level 2 Appeal will explain who to contact and what to do to ask for a
Level 3 Appeal.
For most situations that involve appeals, the last three
levels of
appeal work in much the same way. Here is who handles the
review of your appeal at each of these levels.
|
Level 3
Appeal |
A judge who works for the Federal government will
review your appeal and give you an answer. This judge is called an
"Administrative Law Judge." |
| If the answer is yes, the appeals process is over. What you asked for
in the appeal has been approved. |
| If the answer is no, the appeals process may or may not be
over. |
| If you decide to accept this decision that turns down your appeal, the
appeals process is over. |
| If you do not want to accept the decision, you can continue to the next
level of the review process. If the administrative judge says no to your
appeal, the
notice you get will tell you what to do next if you choose to continue
with your appeal. Whenever the reviewer says no to your appeal, the notice
you get will tell you whether the rules allow you to go on to another
level of appeal. If the rules allow you to go on, the written notice will
also tell you who to contact and what to do next if you choose to continue
with your appeal. |
|
Level 4
Appeal |
The Medicare Appeals Council will review your
appeal and give you an answer. The Medicare
Appeals Council works for the Federal government. |
| If the answer is yes, the appeals process is over. What you asked for
in the appeal has been approved. |
| If the answer is no, the appeals process may or may not be
over. |
| If you decide to accept this decision that turns down your appeal, the
appeals process is over. |
| If you do not want to accept the decision, you might be able to continue
to the next level of the review process. It depends on your situation. If
the Medicare Appeals Council says no to your appeal or denies your request
to review the appeal, the notice you get will tell you whether the rules
allow you to go on to a Level 5 Appeal. If the rules allow you to go on,
the written notice will also tell you who to contact and what to do next
if you choose to continue with your appeal. |
|
Level 5
Appeal |
A judge at the Federal District Court will review
your appeal. This is the last stage of the appeals process. |
| This is the last step of the administrative appeals process. |
MAKING COMPLAINTS
SECTION 7 How to make a
complaint about quality of care, waiting times, customer service, or
other concerns
|
? |
If your problem is about decisions related to benefits,
coverage, or payment, then this section is not for you. Instead,
you need to use the process for coverage
decisions and appeals. Go to Section 4 of this chapter. |
Section 7.1 What kinds of
problems are handled by the complaint process?
This section explains how to use the process for making
complaints. The complaint process is used for certain types of problems only.
This includes problems related to quality of care, waiting times, and the
customer service you receive. Here are
examples of the kinds of problems handled by the complaint process.
Listed below are more examples of possible reasons for making a
complaint.
|
These types of complaints are all related to the
timeliness of our actions related to coverage decisions and appeals
The process of asking for a coverage decision and making
appeals is explained in sections 4-6 of this chapter. If you are asking
for a decision or making an appeal, you use that process, not the
complaint process.
However, if you have already asked for a coverage decision
or made an appeal, and you think that our plan is not responding quickly
enough, you can also make a complaint about our slowness. Here are
examples:
| If you have asked us to give you a fast response for a coverage
decision or appeal, and we have said we will not, you can make a
complaint. |
| If you believe our plan is not meeting the deadlines for giving you
a coverage decision or an answer to an appeal you have made, you can
make a complaint. |
| When a coverage decision we made is reviewed and our plan is told
that we must cover or reimburse you for certain drugs, there are
deadlines that apply. If you think we are not meeting these deadlines,
you can make a complaint. |
| When our plan does not give you a decision on time, we are required
to forward your case to the Independent Review Organization. If we do
not do that within the required deadline, you can make a complaint.
|
|
Section 7.2 The formal name
for "making a complaint" is "filing a grievance"
|
Legal
Terms |
| What this section calls a "complaint" is also
called a "grievance." |
| Another term for "making a complaint" is "filing
a grievance." |
| Another way to say "using the process for complaints"
is "using the process for filing a grievance."
|
|
Section 7.3 Step-by-step:
Making a complaint
Step 1: Contact us promptly – either by phone or in
writing.
| Usually, calling COEHA Customer Service is the first step. If there
is anything else you need to do, COEHA
Customer Service will let you know. |
Toll free numbers:
1-800-679-9135
862-5728 for local residents in the Clifton Forge, VA
area
TTY/TTD users call 711 for all states
Hours of Operation are 8:30am to 5:00pm, Monday through
Friday (EST)
| If you do not wish to call (or you called and were not
satisfied), you can put your complaint in writing and send it to us. If
you do this, it means that we will use our formal procedure for
answering grievances. Here’s how it works: |
| You may file a written grievance with the Administrator of COEHA within
60 days of the event underlying the complaint. The written grievance must
include your name, COEHA identification number,
address and a full explanation of your complaint, including specific
dates, persons, places and events relevant to your complaint. Please
include supporting documentation, if any, when filing your written
grievance. |
Internal Review Committee: After your written grievance
is received, the Administrator will review your grievance for completeness. If
the Administrator does not think the grievance is complete, he can request
additional information from you. Once the Administrator deems your grievance
complete, he will refer your grievance to an Internal Committee of three to
five COEHA administrative staff members appointed by the Administrator. The
Internal Committee will review your complaint and make a decision within 30
days of receiving your complaint. The decision will be set forth in writing
with the Internal Committee’s findings and resolution of the complaint.
Finance Committee Review: If you do not agree with the
Internal Committee’s decision, you may request that it be
reviewed by the Finance Committee of the COEHA Board of Directors. To do so,
you must submit a written request for Finance Committee review to the
Administrator within 10 days of receiving the Internal Committee’s decision.
The Administrator will then forward your grievance to the Finance Committee
for review. The Finance Committee will review the grievance file and make a
decision within 30 days of receiving the grievance file. The written decision
will state whether the Finance Committee approves or disapproves the Internal
Committee’s decision, and, if appropriate, will set forth the Finance
Committee’s findings and resolution of the complaint.
Decisions of the Finance Committee are final.
| Whether you call or write, you should contact COEHA Customer Service right
away. The complaint must be made within 60 days after you had the
problem you want to complain about. |
| If you are making a complaint because we denied your request for a
"fast response" to a coverage decision or appeal, we will
automatically give you a "fast" complaint. If you have a
"fast" complaint, it means we will give you an answer within 24
hours. |
|
Legal
Terms |
What this section calls a "fast complaint" is
also called a "fast grievance." |
Step 2: We look into your
complaint and give you our answer.
| If possible, we will answer you right away. If you call us with a
complaint, we may be able to give you an answer on the same phone call. If
your health condition requires us to answer quickly, we will do that. |
| Most complaints are answered in 30 days, but we may take up to 44 days. If
we need more information and the
delay is in your best interest or if you ask for more time, we can take up to 14
more days (44 days total) to answer your complaint. |
| If we do not agree with some or all of your complaint or don’t take
responsibility for the problem you are complaining about, we will let you know.
Our response will include our reasons for this answer. We must respond whether
we agree with the complaint or not. |
Section 7.4 You can also
make complaints about quality of care to the Quality Improvement
Organization
You can make your complaint about the quality of care you
received to our plan by using the step-by-step process outlined above.
When your complaint is about quality of care, you also
have two extra options:
| You can make your complaint to the Quality
Improvement Organization. If you prefer, you can make your complaint
about the quality of care you
received directly to this organization (without making the complaint to
our plan). For more information about Quality Improvement Organizations, look
in Chapter 2, Section 4, of this booklet. If you make a complaint to this
organization, we will work together with them to
resolve your complaint. |
| You can make your complaint to both at the same time. If you wish, you
can make your complaint about quality of care to our plan and also to the
Quality
Improvement Organization. |
SECTION
1 Introduction
Section
1.1 This chapter focuses on ending your membership in our plan
Ending your membership in the COEHA Medicare Part D
Prescription Drug Plan may be voluntary (your own choice) or
involuntary (not your own choice):
| You might leave our plan because you have decided that you want
to leave. |
| There are certain situations, when you may
voluntarily end your membership in the plan.
Section 2 tells you when you can end your membership in the plan. |
| The process for voluntarily ending your membership varies depending on
what type of new coverage you are choosing. Section 3 tells you how
to end your membership in each situation. |
| There are also limited situations where you do not choose to leave, but we
are required to end your membership. Section 5 tells you about situations
when we must end your membership. |
If you are leaving our plan, you must continue to get your
Part D prescription drugs through our plan until your membership ends.
SECTION
2 When can you end your membership in our plan?
You may end your membership in our plan for any reason at any
time. We are an Employer/Union Medicare Part D Prescription Drug Plan and we do
not have an open enrollment/disenrollment period. Although you may leave our
Plan at any time, you may not be able to join another plan at any time.
Section
2.1 Medicare’s Annual Enrollment Period
During Medicare’s fall open enrollment period, the Annual
Enrollment Period, (also known as the "Annual Coordinated Election
Period") is the time when you should review your health and drug coverage
and make a decision about your coverage for the upcoming year.
| When is the Annual Enrollment Period? This happens every year from
November 15 to December 31. |
| What type of plan can you switch to during the
Annual Enrollment Period? During this time, you can review your health
coverage and your prescription drug coverage. You can choose to keep your
current coverage or make changes to your coverage for the upcoming year. If
you decide to change to a new plan, you can choose any of the following
types of plans: |
| Another Medicare prescription drug plan. |
| Original Medicare without a separate Medicare prescription drug
plan. |
| A Medicare Advantage plan. A Medicare
Advantage plan is a plan offered by a private company that contracts
with Medicare to
provide all of the Medicare Part A (Hospital) and Part B (Medical)
benefits. Some Medicare Advantage plans also include Part D prescription
drug coverage. |
| If you enroll in most Medicare Advantage plans, you will be
disenrolled from COEHA Medicare Part D Prescription Drug Plan when
your new plan’s coverage begins. However, if you choose a Private
Fee-For-Service plan without Part D drug coverage, a Medicare Medical
Savings Account plan, or a Medicare Cost Plan, enrollment will not
automatically disenroll you from our plan. You will need to contact
COEHA
Customer Service and find out how to disenroll. |
Note: If you disenroll from a Medicare prescription
drug plan and go without creditable prescription drug coverage, you may need
to pay a late enrollment penalty if you join a Medicare drug plan later.
("Creditable" coverage means the coverage is at least as good as
Medicare’s standard prescription drug coverage.)
| When will your membership end? Your membership will end when your
new plan’s coverage begins on January 1. |
Section
2.2 You can end your membership during the Medicare Advantage Open
Enrollment Period, but your plan choices are more limited
You have the opportunity to make one change to your
health coverage during the Medicare Advantage Open Enrollment Period.
| When is the Medicare Advantage Open Enrollment Period? This happens
every year from January 1 to March 31. |
| What type of plan can you switch to during the Medicare Advantage Open
Enrollment Period? During this time, you can make one change to
your health plan coverage. However, you may not add or drop
prescription drug coverage during this time. Since you are currently enrolled
in a Medicare prescription drug plan, this means that you can enroll in: |
| A Medicare Advantage plan with prescription drug coverage. (A Medicare
Advantage plan is a plan offered by a private company that contracts with
Medicare to provide all of the Medicare Part A (Hospital) and Part B
(Medical) benefits.) |
| When will your membership end? Your membership will end on the first
day of the month after we get your request to change plans. |
Section
2.3 In certain situations, you can end your membership during a
Special Enrollment Period
In certain situations, members of other prescription drug
plans may be eligible to end their membership at
other times of the year. This is known as a Special Enrollment Period.
| Who is eligible for a Special Enrollment Period? If any of the
following situations apply to you, you are
eligible to end your membership during a Special Enrollment Period. These
are just examples, for the full list you can contact the plan, call
Medicare, or visit the Medicare website (http://www.medicare.gov): |
| If you have moved out of your plan’s service area. |
| If you have Medicaid. |
| If you are eligible for Extra Help with paying for your Medicare
prescriptions. |
| If you live in a facility, such as a nursing home. |
| When are Special Enrollment Periods? The enrollment periods vary
depending on your situation. |
| What can you do? If you are eligible to end your membership because
of a special situation, you can choose to change both your Medicare health
coverage and prescription drug coverage. This means you can choose any of
the following types of plans: |
| Another Medicare prescription drug plan. |
| Original Medicare without a separate Medicare prescription drug
plan. |
| A Medicare Advantage plan. A Medicare
Advantage plan is a plan offered by a private company that contracts
with Medicare to
provide all of the Medicare Part A (Hospital) and Part B (Medical)
benefits. Some Medicare Advantage plans also include Part D prescription
drug coverage. |
| If you enroll in most Medicare Advantage plans, you will
automatically be disenrolled from COEHA Medicare Part D Prescription
Drug Plan when your new plan’s coverage begins. However, if you
choose a Private Fee-For-Service plan without Part D drug coverage, a
Medicare Medical Savings Account plan, or a Medicare Cost Plan,
enrollment will not
automatically disenroll you from our plan. You will need to contact
COEHA Customer Service and find out how to disenroll. |
Note: If you disenroll from a Medicare prescription
drug plan and go without creditable prescription drug coverage, you may need
to pay a late enrollment penalty if you join a Medicare drug plan later.
("Creditable" coverage means the coverage is at least as good as
Medicare’s standard prescription drug coverage.)
| When will your membership end? Your membership will usually end on
the first day of the month after we receive your request to change your
plan. |
Section
2.4 Where can you get more information about when you can end your
membership?
If you have any questions or would like more information on
when you can end your membership:
| You can call COEHA Customer Service (phone numbers are on the
front inside cover of this booklet). |
| You can find the information in the Medicare & You 2010
handbook. |
| Everyone with Medicare receives a copy of Medicare & You
each fall. Those new to Medicare receive it within a month after first
signing up. |
| You can also download a copy from the Medicare website (http://www.medicare.gov).
Or, you can order a printed copy by calling Medicare at the number
below. |
| You can contact Medicare at 1-800-MEDICARE
(1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048. |
SECTION
3 How do you end your membership in our plan?
Section
3.1 You end your membership by enrolling in another plan
Usually, to end your membership in our plan, you simply
enroll in another Medicare plan during one of the enrollment periods (see
Section 2 for information about the enrollment periods). There is an exception:
One exception is if you join a Private Fee-For-Service
plan without prescription drug coverage, a Medicare Medical Savings
Account Plan, or a Medicare Cost Plan. You will need to disenroll from our
plan. Contact COEHA Customer Service to find out how to disenroll from our
plan.
The table on the next page explains how you should end your
membership in our plan.
|
If you would like to switch from our plan to: |
|
This is what you should do: |
| Another Medicare prescription drug plan. |
|
| Enroll in the new Medicare prescription drug plan. |
You will automatically be disenrolled from COEHA
Medicare Part D Prescription Drug Plan when your new plan’s coverage
begins.
|
| A Medicare Advantage plan.
|
|
| Enroll in the Medicare
Advantage plan. |
With most Medicare Advantage plans, you will
automatically be disenrolled from COEHA Medicare Part D Prescription
Drug Plan when your new plan’s coverage begins.
However, if you choose a Private Fee-For-Service
plan without Part D drug coverage, a Medicare Medical Savings
Account plan, or a Medicare Cost Plan, you must disenroll from our
plan.
Contact COEHA Customer Service and ask to be
disenrolled from the plan.
|
SECTION
4 Until your membership ends, you must keep getting your drugs
through our plan
Section
4.1 Until your membership ends, you are still a member of our plan
If you leave COEHA Medicare Part D Prescription Drug Plan, it
may take time before your membership ends and your new Medicare coverage goes
into effect. (See Section 2 for information on when your new coverage begins.)
During this time, you must
continue to get your prescription drugs through our plan.
| You should continue to use the Informed RX network pharmacies to get your
prescriptions filled until your membership in our plan ends. Usually,
your prescription drugs are only covered if they are filled at a network
pharmacy, including through the Informed RX
mail-order pharmacy services. |
SECTION
5 COEHA Medicare Part D Prescription Drug Plan must end your
membership in the plan in certain situations
Section
5.1 When must we end your membership in the plan?
COEHA Medicare Part D Prescription Drug Plan must end your
membership in the plan if any of the following happen:
| If you do not stay continuously enrolled in Medicare Part A or Part B (or
both). |
| If you lie about or withhold information about other insurance you have
that provides prescription drug coverage. |
| If you intentionally give us incorrect information when you are enrolling
in our plan and that information affects your eligibility for our plan. |
| If you continuously behave in a way that is disruptive and makes it
difficult for us to provide care for you and other members of our plan. |
| We cannot make you leave our plan for this reason unless we get
permission from Medicare first. |
| If you let someone else use your membership card to get prescription
drugs. |
| If we end your membership because of this reason, Medicare may have your
case investigated by the Inspector General. |
| If you do not pay the plan premiums. |
| We must notify you in writing that you have 90 days to pay the
plan premium before we end your membership. |
Where can you get more information?
If you have questions or would like more information on when
we can end your membership:
| You can call COEHA Customer Service for more information (phone
numbers are on the front inside cover of this booklet). |
Section
5.2 We cannot ask you to leave our plan for any reason
related to your health
What should you do if this happens?
If you feel that you are being asked to leave our plan
because of a health-related reason, you may call Medicare 24 hours a day,
7 days a week at 1-800-MEDICARE (1-800-633-4227). TTY users should
call 1-877-486-2048.
Section
5.3 You have the right to make a complaint if we end your membership
in our plan
If we end your membership in our plan, we must tell you our
reasons in writing for ending your membership. We must also explain how you can
make a complaint about our decision to end your membership. You can also look in
Chapter 7, Section 7 for information about how to make a complaint.
SECTION 1
Notice about governing law
Many laws apply to this Evidence of Coverage and some
additional provisions may apply because they are required by law. This may
affect your rights and responsibilities even if the laws are not
included or explained in this document. The principal law that
applies to this document is Title XVIII of the Social Security Act and the
regulations created under the Social Security Act by the
Centers for Medicare & Medicaid Services, or CMS. In addition, other Federal
laws may apply and, under certain circumstances, the laws of the state you live
in.
SECTION
2 Notice about nondiscrimination
We don’t discriminate based on a person’s race,
disability, religion, sex, health, ethnicity, creed, age, or national origin.
All
organizations that provide Medicare Advantage Plans, like our plan, must obey
Federal laws against discrimination, including Title VI of the Civil Rights Act
of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the
Americans with Disabilities Act, all other laws that apply to organizations that
get Federal funding, and any other laws and rules that apply for any other
reason.
Chapter 10. Definitions of important
words
Appeal – An appeal is something you do if you disagree
with a decision to deny a request for health care services or prescription drugs
or payment for services or drugs you already received. You may also make an
appeal if you disagree with a decision to stop services that you are receiving.
For example, you may ask for an appeal if our Plan doesn’t pay for a drug,
item, or service you think you should be able to receive. Chapter 7 explains
appeals, including the process involved in making an appeal.
Brand Name Drug – A prescription drug that is
manufactured and sold by the pharmaceutical company that originally researched
and developed the drug. Brand name drugs have the same active-ingredient formula
as the generic version of the drug. However, generic drugs are manufactured and
sold by other drug manufacturers and are generally not available until after the
patent on the brand name drug has expired.
Catastrophic Coverage Stage – The stage in the Part D
Drug Benefit where you pay a low copayment or coinsurance for your drugs after
you or other qualified parties on your behalf have spent $4550.00
in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) –
The
Federal agency that runs Medicare. Section 2 explains how to contact CMS.
COEHA Customer Service – A department within our Plan
responsible for answering your questions about your membership, benefits,
grievances, and appeals. See Chapter 2 for information about how to contact
COEHA Customer Service.
Cost-sharing – Cost-sharing refers to amounts that a
member has to pay when drugs are received. It includes any combination of the
following three types of payments: (1) any deductible amount a plan may impose
before drugs are covered; (2) any fixed "copayment" amounts that a
plan may require be paid when specific drugs are received.
Coverage Determination – A decision about
whether a drug prescribed for you is covered by the plan and the amount, if any,
you are required to pay for the prescription. In general, if you bring your
prescription to a pharmacy and the pharmacy tells you the prescription isn’t
covered under your plan, that isn’t a coverage determination. You need to call
or write to your plan to ask for a formal decision about the coverage if you
disagree.
Covered Drugs – The term we use to mean all of the
prescription drugs covered by our Plan.
Creditable Prescription Drug Coverage – Prescription
drug coverage (for example, from an employer or union) that is expected to
cover, on average, at least as much as Medicare’s standard prescription drug
coverage. People who have this kind of coverage when they become eligible for
Medicare can generally keep that coverage without paying a penalty, if they
decide to enroll in Medicare prescription drug coverage later.
Deductible – The amount you must pay before our Plan
begins to pay its share of your covered drugs.
Disenroll or Disenrollment – The process of
ending your membership in our Plan. Disenrollment may be voluntary (your own
choice) or involuntary (not your own choice).
Evidence of Coverage (EOC) and Disclosure Information –
This document, along with your enrollment form and any other attachments,
riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as
a member of our Plan.
Exception – A type of coverage determination that, if
approved, allows you to get a drug that is not on your plan sponsor’s
formulary (a formulary exception). You may also request an exception if your
plan sponsor requires you to try another drug before receiving the drug you are
requesting, or the plan limits the quantity or
dosage of the drug you are requesting (a formulary exception).
Generic Drug – A prescription drug that is approved by
the Food and Drug Administration (FDA) as having the same active ingredient(s)
as the brand-name drug. Generally, generic drugs cost less than brand-name
drugs.
Grievance – A type of complaint you make about us or
one of the Informed RX network pharmacies, including a complaint concerning the
quality of your care. This type of complaint does not
involve coverage or payment disputes.
Initial Coverage Limit – The maximum limit of coverage
under the Initial Coverage Stage.
Initial Coverage Stage – This is the stage after you
have met your deductible and before your total drug expenses, have reached
$5000.00, including amounts you’ve paid and what our Plan has paid on your
behalf.
Late Enrollment Penalty – An amount added to your
monthly premium for Medicare drug coverage if you go without creditable coverage
(coverage that expects to pay, on average, at least as much as standard Medicare
prescription drug coverage) for a continuous period of 63 days or more. You pay
this higher amount as long as you have a Medicare drug plan. There are some
exceptions.
List of Covered Drugs (Formulary or "Drug List")
– A list of covered drugs provided by the plan. The drugs on this list are
selected by the plan with the help of doctors and pharmacists. The list includes
both brand-name and generic drugs.
Low Income Subsidy/Extra Help
– A Medicare program to help people with limited income and resources
pay Medicare prescription drug program costs, such as premiums, deductibles, and
coinsurance.
Medically Necessary – Drugs that are proper and needed
for the diagnosis or treatment of your medical condition; are used for the
diagnosis, direct care, and treatment of your medical condition; meet the
standards of good medical practice in the local
community; and are not mainly for your convenience or that of your doctor.
Medicare – The Federal health insurance program for
people 65 years of age or older, some people under age 65 with certain
disabilities, and people with End-Stage Renal Disease (generally those with
permanent kidney failure who need dialysis or a kidney transplant).
Medicare Advantage (MA) Plan – Sometimes called
Medicare Part C. A plan offered by a private company that contracts with
Medicare to provide you with all your Medicare Part A (Hospital) and Part B
(Medical) benefits. A MA plan offers a specific set of health benefits at the
same premium and level of cost-sharing to all people with Medicare who live in
the service area covered by the Plan. Medicare Advantage Organizations can offer
one or more Medicare Advantage plan in the same service area. A Medicare
Advantage plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a
Medicare Medical Savings Account (MSA) plan. In most cases, Medicare Advantage
Plans also offer Medicare Part D (prescription drug coverage). These plans are
called Medicare Advantage Plans with Prescription Drug Coverage. Everyone
who has Medicare Part A and Part B is eligible to join any Medicare Health Plan
that is offered in their area, except people with End-Stage Renal Disease
(unless certain exceptions apply).
Medicare Prescription Drug Coverage (Medicare Part D) –
Insurance to help pay for outpatient prescription drugs, vaccines, biologicals,
and some supplies not covered by Medicare Part A or Part B.
"Medigap" (Medicare Supplement Insurance) Policy
– Medicare supplement insurance sold by private insurance companies to fill
"gaps" in Original Medicare. Medigap policies only work with Original
Medicare. (A Medicare Advantage plan is not a Medigap policy.)
Member (Member of our Plan, or "Plan Member")
– A person with Medicare who is eligible to get covered services, who has
enrolled in our Plan and whose enrollment has been confirmed by the Centers for
Medicare & Medicaid Services (CMS).
Network Pharmacy – A network pharmacy is a
pharmacy where members of our Plan can get their prescription drug benefits. We
call them "network pharmacies" because they contract with
Informed RX, our Pharmacy Benefits Manager. In most cases, your prescriptions
are covered only if they are filled at one of the Informed RX network
pharmacies.
Original Medicare ("Traditional Medicare" or
"Fee-for-service" Medicare) – Original Medicare is offered by the
government, and not a private health plan like Medicare Advantage plans and
prescription drug plans. Under Original Medicare, Medicare services are covered
by paying doctors, hospitals and other health care providers payment amounts
established by Congress. You can see any doctor, hospital, or other health care
provider that accepts Medicare. You must pay the deductible. Medicare pays its
share of the Medicare-approved amount, and you pay your share. Original Medicare
has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is
available everywhere in the United States.
Out-of-network Pharmacy – A pharmacy that doesn’t
have a contract with Informed RX to coordinate or provide covered drugs to
members of our Plan. As explained in this Evidence of Coverage, most drugs you
get from out-of-network pharmacies are not covered by our Plan unless certain
conditions apply.
Part C – see "Medicare Advantage (MA) Plan".
Part D – The voluntary Medicare Prescription Drug
Benefit Program. (For ease of reference, we will refer to the prescription drug
benefit program as Part D.)
Part D Drugs – Drugs that can be covered under Part D.
We may or may not offer all Part D drugs. (See your formulary for a
specific list of covered drugs.) Certain categories of drugs were specifically
excluded by Congress from being covered as Part D drugs.
Prior Authorization – Approval in advance to get
certain drugs that may or may not be on our formulary. Some drugs are covered
only if your doctor or other network provider gets "prior
authorization" from us. Covered drugs that need prior authorization are
marked in the formulary.
Quality Improvement Organization (QIO) – Groups of
practicing doctors and other health care experts that are paid by the Federal
government to check and improve the care given to Medicare patients. They must
review your complaints about the quality of care given by Medicare Providers.
See Chapter 2 for information about how to contact the QIO in your state and
Chapter 7 for
information about making complaints to the QIO.
Quantity Limits – A management tool that is designed to
limit the use of selected drugs for quality, safety, or utilization reasons.
Limits may be on the amount of the drug that we cover per prescription or for a
defined period of time.
Service Area – "Service
area" is the geographic area approved by the Centers for Medicare &
Medicaid Services (CMS) within which an eligible individual may enroll in a
certain plan, and in the case of network plans, where a network must be
available to
provide services. Our Plan does not have a designated service area. Our
coverage is portable—you will never lose coverage by moving to a different
state within the United States.
Step Therapy – A utilization tool that requires you to
first try another drug to treat your medical condition before we will cover the
drug your physician may have initially prescribed.
Supplemental Security Income (SSI) – A monthly
benefit paid by the Social Security Administration to people with limited
income and resources who are disabled, blind, or age 65 and older. SSI benefits
are not the same as Social Security benefits.
|
