Medicare Part D

CHAPTER ONE, SECTION 1: INTRODUCTION

Section 1.1 You are enrolled in the C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan, which is a Medicare Prescription Drug 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.

There are different types of Medicare plans. C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and run by a private company.

Section 1.2 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.

This plan, C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan, is offered by C and O Employees’ Hospital Association (“ COEHA”). (When this Evidence of Coverage says “we,” “us,” or “our,” it means COEHA. When it says “plan” or “our plan,” it means C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan.

The word “coverage” and “covered drugs” refers to the prescription drug coverage available to you as a member of C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan.

Section 1.3 What does this Chapter tell you?

Look through Chapter 1 of this Evidence of Coverage to learn:

What makes you eligible to be a plan member?

· What is your plan’s service area?

· What materials will you get from us?

· What is your plan premium and how can you pay it?

· How do you keep the information in your membership record up to date?

Section 1.4 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 Service (contact information is on the front inside cover of this booklet).

Section 1.5 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, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called “riders” or “amendments.”

The contract is in effect for the months in which you are enrolled in C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan between January 1, 2012 and December 31, 2012.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services) must approve C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan each year. You can continue to get Medicare coverage as a member of our plan only as long as we choose to continue to offer the plan for the year in question and the Centers for Medicare & Medicaid Services renews its approval of the plan.

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 B, you must continue paying your premium in order to keep your Medicare Part A and B and remain a member of this plan and also fall in one of the following categories:

	Medicare retiree from COEHA or any other Railroad
	Medicare spouse or widow(er) of COEHA or other Railroad member
	Medicare dependent child of current or former COEHA and other Railroad member
	Medicare parent or parent-in-law of COEHA or other Railroad member

· Former COEHA members who discontinued membership in the COEHA, including those who were employees of the former C&O Hospitals in Clifton Forge, VA and Huntington, WV

· Former employees of The Greenbrier Hotel with Medicare coverage

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 institutional 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) and certain items (such as durable medical equipment and supplies).

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 your COEHA/Informed RX card for prescription drugs you get at network pharmacies. Here’s a sample membership card to show you what yours will look like:

C&O.jpg

Some membership cards still show COEHA/NMHC RX. You may use these cards also. Please carry your card with you at all times and remember to show your card when you get covered drugs. If your plan membership card is damaged, lost, or stolen, call COEHA Customer Service right away and we will send you a new card.

You may need to use your red, white, and blue Medicare card to get covered medical care and services under Original Medicare.

Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network

As a member of our plan, Informed RX will send you a Pharmacy Directory or an update to your Pharmacy Directory upon request. This directory lists their main network pharmacies.

What are “network pharmacies”?

The Informed RX Pharmacy Directory gives you a complete list of the main network pharmacies, which means all of the pharmacies that have agreed to fill covered prescriptions for our plan members.

Why do you need to know about network pharmacies?

You can use the Pharmacy Directory to find the network pharmacy you want to use. This is important because, with few exceptions, you must get your prescriptions filled at one of the Informed RX network pharmacies if you want our plan to cover (help you pay for) them.

If you don’t have the Pharmacy Directory, you can get a copy from Informed RX Customer Service at 1-866-443-1095. At any time, you can call Informed RX Customer Service to get up-to-date information about changes in the pharmacy network. You can also find this information on their website at http://www.myinformedrx.com.

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.

The Drug List also tells you if there are any rules that restrict coverage for your drugs.

The Drug List includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. To get the most complete and current information about which drugs are covered, you can visit the plan’s website at www.coeha.com or call Informed RX Customer Service at 1-866-443-1095 or check their website at http://www.myinformedrx.com.

Section 3.4 The Explanation of Benefits (the “EOB”): Reports with a summary of payments made for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report, upon request, to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Explanation of Benefits (or the “EOB”).

The Explanation of Benefits tells you the total amount you have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about the Explanation of Benefits and how it can help you keep track of your drug coverage.

SECTION 4 Your monthly premium for C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan

S ection 4.1 How much is your plan premium?

As a member of our plan, you pay a monthly plan premium which also includes payment for your membership in the COEHA Supplemental Plan. For 2012, the monthly premium for C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan is $260.00. In addition, you must continue to pay your Medicare Part B premium.

In some situations, your plan premium could be less

There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. Chapter 2, Section 7 tells more about these programs. If you qualify, enrolling in the program might lower your monthly plan premium.

If you are already enrolled and getting help from one of these programs, the information about premiums in this Evidence of Coverage may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider), which tells you about your drug coverage. If you don’t have this insert, please call COEHA Customer Service and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Phone numbers for COEHA Customer Service are on the inside front cover of this booklet.

In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount listed above in Section 4.1. These situations are described below.

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 have “creditable” prescription drug coverage. (“Creditable” means the drug coverage is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) For these members, the late enrollment penalty is added to the plan’s monthly premium. Their premium amount 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 9 explains the late enrollment penalty.
	If you have a late enrollment penalty and do not pay it, you could be disenrolled from the plan.

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 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	www.medicare.gov

SECTION 4 Quality Improvement Organization
(paid by Medicare to check on the quality of care for people with Medicare) (“QIO”)

There is a Quality Improvement Organization for each state. The QIO has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. QIO is an independent organization. It is not connected with our plan.

You should contact QIO if you have a complaint about the quality of care you have received. For example, you can contact QIO if you were given the wrong medication or if you were given medications that interact in a negative way.

Quality Improvement Organization (“QIO”) (paid by Medicare to check on the quality of care for people with Medicare)
CALL	Call the national Medicare @ 1-800-633-4227
TTY	Call 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
WEBSITE	www.medicare.gov

SECTION 5 Social Security

The Social Security Administration is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office.

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 Social Security’s 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.

In addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These programs help people with limited income and resources save money each year:

· Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments).

· Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI): Helps pay Part B premiums.

· Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.

To find out more about Medicaid and its programs, contact

Medicaid
CALL	Call the national Medicare @ 1-800-633-4227
TTY	1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
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.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:

	1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
	The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
	Your State Medicaid Office. (See Section 6 of this chapter for contact information)

If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper co-payment level, or, if you already have the evidence, to provide this evidence to us.

· We will assist our member upon request to get Extra Help in obtaining the best available evidence by contacting their pharmacist, patient advocate, Social Security or Medicaid office.

· When we receive the evidence showing your copayment level, we will have Informed RX update their system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, Informed RX will reimburse you. They will either forward a check to you in the amount of your overpayment or they will offset future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, Informed RX may make the payment directly to the pharmacy. If a state paid on your behalf, Informed RX may make payment directly to the state. Please contact COEHA Customer Service if you have questions.

Medicare Coverage Gap Discount Program

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enrollees who have reached the coverage gap and are not already receiving “Extra Help.” A 50% discount on the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) is available for those brand name drugs from manufacturers that have agreed to pay the discount.

If you reach the coverage gap, Informed RX will automatically apply the discount when your pharmacy bills you for your prescription and your Explanation of Benefits (EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap.

You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays 14% of the price for generic drugs and you pay the remaining 86% of the price. The coverage for generic drugs works differently than the 50% discount for brand name drugs. For generic drugs, the amount paid by the plan (14%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug.

If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact COEHA Customer Service (phone numbers are on the front inside cover of this booklet).

What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?

If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than Extra Help), you still get the 50% discount on covered brand name drugs. The 50% discount is applied to the price of the drug before any SPAP or other coverage.

What if you get Extra Help from Medicare to help pay your prescription drug costs? Can you get the discounts?

No. If you get Extra Help, you already get coverage for your prescription drug costs during the coverage gap.

What if you don’t get a discount, and you think you should have?

If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should request from us an Explanation of Benefits (EOB) notice. If the discount doesn’t appear on your Explanation of Benefits, you should contact us to make sure that your prescription records are correct and up-to-date. If we don’t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this Chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

State Pharmaceutical Assistance Programs

Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules to provide drug coverage to its members.

These programs provide limited income and medically needy seniors and individuals with disabilities financial help for prescription drugs.

State Pharmaceutical Assistance Programs (SPAP)
CALL	Call the national Medicare @ 1-800-633-4227
TTY	Call 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
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 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.

CHAPTER 3, SECTION 1

Introduction

Did you know there are programs to help

people pay for their drugs?

There are programs to help people with limited resources pay for their drugs.

These include “Extra Help” and State Pharmaceutical Assistance Programs.

For more information, see Chapter 2, Section7.

Are you currently getting help to pay for

your drugs?

If you are in a program that helps pay for your drugs, some information in this

Evidence of Coverage about the costs for Part D prescription drugs may not

apply to you. We will send you a separate insert, called the “Evidence of

Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider), that tells you about your drug coverage. If you receive this insert,

please call COEHA Customer Service and ask for the “Evidence of Coverage

Rider for People Who Get Extra Help Paying for Prescription Drugs”

(LIS Rider). Phone numbers for COEHA Customer Service are on the inside

front cover.

Section 1.1 This chapter describes your coverage for Part D drugs

This chapter explains rules for using your coverage for Part D drugs. The next chapter tells what you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs).

In addition to your coverage for Part D drugs through our plan, Original Medicare (Medicare Part A and Part B) also covers some drugs:

· Medicare Part A covers drugs you are given during Medicare-covered stays in the hospital or in a skilled nursing facility.

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.) Your Part D prescription drugs are covered under our plan. This chapter explains rules for using your coverage for Part D drugs under our plan. The next chapter tells what you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs).

Section 1.2 Basic rules for the plan’s Part D drug coverage

The plan will generally cover your drugs as long as you follow these basic rules:

	You must have a provider (a doctor or other prescriber) write your prescription.
	You must use an Informed RX pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a network pharmacy or through the plan’s mail-order service).
	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 used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more information about a medically accepted indication.)

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 Informed RX network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.)

A network pharmacy is a pharmacy that has a contract with Informed RX to provide your covered prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are covered on the plan’s Drug List.

Section 2.2 Finding network pharmacies

How do you find a network pharmacy in your area?

To find a network pharmacy, you can look in your Pharmacy Directory, visit the Informed RX, http://myinformedrx.com, call Informed RX Customer Service at 1-866-443-1095 or visit our website www.coeha.com, or call COEHA Customer Service (phone numbers are on the front inside cover of this booklet). Choose whatever is easiest for you.

You may go to any of the Informed RX network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask to have a new prescription written by a doctor or to have your prescription transferred to your new network pharmacy.

What if the pharmacy you have been using leaves the network?

If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from Informed RX Customer Service or use the Pharmacy Directory.

What if you need a specialized pharmacy?

Sometimes prescriptions must be filled at a specialized pharmacy. The Informed RX network does have specialized pharmacies. Specialized pharmacies include:

	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 drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: This scenario should happen rarely.)

To locate a specialized pharmacy, look in your Pharmacy Directory or call Informed RX Customer Service.

Section 2.3 Using the plan’s mail-order services

Our plan’s mail-order service through Informed RX is mainly used for 90-day fills.

To get order forms and information about filling your prescriptions by mail, please call Informed RX Customer Service. If you use a mail-order pharmacy not in the Informed RX network, your prescription will not be covered.

Usually a mail-order pharmacy order will get to you in no more than 14 days. You should call Informed RX or COEHA Customer Service if your mail order is delayed.

Section 2.4 How can you get a long-term supply of drugs?

When you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two ways to get a long-term supply of “mail-order” drugs on our plan’s Drug List. (Mail-order drugs are usually drugs that you take on a regular basis, for a chronic or long-term medical condition.)

Some local retail pharmacies in the Informed RX 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 a long-term 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 days fills for mail-order copayments. You can also call COEHA Customer Service for more information.
For certain kinds of drugs, you can use the Informed RX mail-order services. The mail-order service allows you to order up to a 90-day supply of the drug. See Section 2.3 for more information about using our mail-order services.

Section 2.5 When can you use a pharmacy that is not in the Informed RX network?

Your prescription may be covered in certain situations

We cover drugs filled at an out-of-network pharmacy only under emergency circumstances when you are not able to use a network pharmacy.

In these situations, please check first with Informed RX Customer Service to see if there is a network pharmacy nearby.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to pay you back.)

SECTION 3 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 use of the drug meets the following criteria of a “medically accepted indication”. A “medically accepted indication” is a use of the drug that is either:

	approved by the Food and Drug Administration. (The Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.)
	-- or -- supported by certain reference books. (These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor.)

The Drug List includes both brand name and generic drugs

A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs.

What is not on the Drug List?

The plan does not cover all prescription drugs.

· In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more about this, see Section 7.1 in this chapter).

· In other cases, we have decided not to include a particular drug on our Drug List.

Section 3.2 There are three “cost-sharing tiers” for drugs on the Drug List

Every drug on the plan’s Drug List is in one of three cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug:

· Tier is for generic medications

· Tier 2 is for preferred brand medication

· Tier 3 is for “non-preferred” medications. These medications have a less expensive, clinical alternative medication available on Tier 2

Tier One is the least expensive and Tier Three is the most expensive.

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

The amount you pay for drugs in each cost-sharing tier is shown in Chapter 4 (What you pay for your Part D prescription drugs).

Section 3.3 How can you find out if a specific drug is on the Drug List?

You have three ways to find out:

1. Visit the plan’s website www.coeha.com. The Drug List on the website is always the most current.

2. Call Informed RX Customer Service to find out if a particular drug is on the plan’s Drug List or to ask for a copy of the list. Call 1-866-443-1095.

3. Visit the Informed RX website, http://www.myinformedrx.com .

SECTION 4 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 to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.

If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the formal appeals process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)

Section 4.2 What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs.

Getting plan approval in advance

For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.

Quantity limits

For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how many refills you can get, or how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

Section 4.3 Do any of these restrictions apply to your drugs?

The plan’s Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call Informed RX Customer Service, check their website at http://myinformedrx.com, or check our website at www.coeha.com.

If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact COEHA Customer Service to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the formal appeals process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)

SECTION 5 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 provider think you should be taking. We hope that your drug coverage will work well for you, but it’s possible that you might have a problem. For example:

· What if the drug you want to take is not covered by the plan? For example, the drug might not be covered at all. Maybe a generic version of the drug is covered but the brand name version you want to take is not covered.

· What if the drug is covered, but there are extra rules or restrictions on coverage for that drug? As explained in Section 4, some of the drugs covered by the plan have extra rules to restrict their use. For example, there might be limits on what amount of the drug (number of pills, etc.) is covered during a particular time period. In some cases, you may want us to waive the restriction for you. For example, you may want us to cover more of a drug (number of pills, etc.) than we normally will cover.

· What if the drug is covered, but it is in a cost-sharing tier that makes your cost sharing more expensive than you think it should be? The plan puts each covered drug into one of three different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in.

There are things you can do if your drug is not covered in the way that you’d like it to be covered. Your options depend on what type of problem you have:

· If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn what you can do.

· If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to Section 5.3 to learn what you can do.

Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way?

If your drug is not on the Drug List or is restricted, here are things you can do:

· You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.

· You can change to another drug.

· You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

· The drug you have been taking is no longer on the plan’s Drug List.

· -- or -- the drug you have been taking is now restricted in some way (Section 4 in this chapter tells about restrictions).

2. You must be in one of the situations described below:

For those members who were in the plan last year 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 the calendar year. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. The prescription must be filled at an Informed RX network pharmacy.

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 an Informed RX network pharmacy.

For those who are a new member and reside 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 in the plan for more than 90 days and reside in 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.

For those current members with level of care changes:

We will cover one 31-day supply, or less if your prescription is written for fewer days. This is an addition to the above long-term transition supply.

To ask for a temporary supply, call Informed RX Customer Service at 1-866-443-1095.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options.

You can change to another drug

Start by talking with your provider. Perhaps there is a different drug covered by the plan that might work just as well for you. You can call Informed RX Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you.

You can ask for an exception

You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List. You can ask the plan to make an exception and cover the drug without restrictions.

If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for the following year. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for the following year. We will give you an answer to your request for an exception before the change takes effect.

If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.

Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high?

If your drug is in a cost-sharing tier you think is too high, here are things you can do:

You can change to another drug

If your drug is in a cost-sharing tier you think is too high, start by talking with your provider. Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you. You can call Informed RX Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you.

You can ask for an exception

For drugs in the three tiers, you and your provider can ask the plan to make an exception in the cost-sharing tier for the drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule.

Drugs in some of our cost-sharing tiers are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs in tiers one and two

SECTION 6 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.

· Move a drug to a higher or lower cost-sharing tier.

· Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 4 in this chapter).

· Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List.

Section 6.2 What happens if coverage changes for a drug you are taking?

How will you find out if your drug’s coverage has been changed?

If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time.

Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. Your provider will also know about this change, and can work with you to find another drug for your condition.

Do changes to your drug coverage affect you right away?

If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan:

· If we move your drug into a higher cost-sharing tier.

· If we put a new restriction on your use of the drug.

· If we remove your drug from the Drug List, but not because of a sudden recall or because a new generic drug has replaced it.

If any of these changes happens for a drug you are taking, then the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes will affect you.

In some cases, you will be affected by the coverage change before January 1:

· If a brand name drug you are taking is replaced by a new generic drug, the plan must give you at least 60 days’ notice or give you a 60-day refill of your brand name drug at a network pharmacy.

o During this 60-day period, you should be working with your provider to switch to the generic or to a different drug that we cover.

o You and your provider can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 7 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]).

· If a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away.

o Your provider will also know about this change, and can work with you to find another drug for your condition.

SECTION 7 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.” This means Medicare does not pay for these drugs.

If you get drugs that are excluded, you must pay for them yourself. We won’t pay for the drugs that are listed in this section (except for certain excluded drugs covered under our enhanced drug coverage). The only exception: If the requested drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid for or covered it because of your specific situation. (For information about appealing a decision we have made to not cover a drug, go to Chapter 7, Section 5.5 in this booklet.)

Here are three general rules about drugs that Medicare drug plans will not cover under Part D:

· Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.

· Our plan cannot cover a drug purchased outside the United States and its territories.

· Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

o Generally, coverage for “off-label use” is allowed only when the use is supported by certain reference books. These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor. If the use is not supported by any of these reference books, then our plan cannot cover its “off-label use.”

Also, by law, these categories of drugs are not covered by Medicare drug plans: (Our plan covers certain drugs listed below through our enhanced drug coverage, for which you may be charged an additional premium. More information is provided below.)

· Non-prescription drugs (also called over-the-counter drugs) with the exception of Prilosec OTC, Claritin OTC, Zyrtec OTC and Allegra OTC

· Drugs when used to promote fertility

· Drugs when used for the relief of cough or cold symptoms

· Drugs when used for cosmetic purposes or to promote hair growth

· Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

· Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject

· Drugs when used for treatment of anorexia, weight loss, or weight gain

· Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

· Barbiturates and Benzodiazepines

We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage). As listed above under non-prescription drugs, we do cover the following over-the-counter drugs. There is no copayment due by you for these drugs, therefore, these drugs do not count towards qualifying you for the Catastrophic Cover Stage. (The Catastrophic Coverage Stage is described in Chapter 4, Section 7 of this booklet.)

· Prilosec OTC

· Claritin OTC

· Zyrtec OTC

· Allegra OTC

In addition, if you are receiving Extra Help from Medicare to pay for your prescriptions, the Extra Help program will not pay for the drugs not normally covered. (Please refer to your formulary or call Informed RX Customer Service for more information.) However, if you have drug coverage through Medicaid, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.)

SECTION 8 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 Informed RX with you when you fill your prescription, ask the pharmacy to call the plan to get the necessary information.

If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 5, Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 9 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 Original Medicare?

If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage.

If you are admitted to a skilled nursing facility for a stay covered by Original Medicare, Medicare Part A will generally cover your prescription drugs during all or part of your stay. If you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage.

Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a special enrollment period. During this time period, you can switch plans or change your coverage at any time. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan and join a different Medicare plan.)

Section 9.2 What if you’re a resident in a long-term care facility?

Usually, a long-term care facility (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility’s pharmacy as long as it is part of our network.

Check your Pharmacy Directory to find out if your long-term care facility’s pharmacy is part of our network. If it isn’t, or if you need more information, please contact Informed RX Customer Service.

What if you are a resident in a long-term care facility and become a new member of the plan?

If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a temporary supply of your drug during the first 90 days of your membership. The first supply will be for a maximum of a 31-day supply or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days in the plan.

If you have been a member of the plan for more than 90 days and need a drug that is not on our Drug List or if the plan has any restriction on the drug’s coverage, we will cover one 31-day supply, or less if your prescription is written for fewer days.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do.

Section 9.3 What if you are taking drugs covered by Original Medicare?

Your enrollment in the COEHA Medicare Part D Prescription Drug Plan doesn’t affect your coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In addition, if your drug would be covered by Medicare Part A or Part B, our plan can’t cover it, even if you choose not to enroll in Part A or Part B.

Some drugs may be covered under Medicare Part B in some situations and through COEHA Medicare Part D Prescription Drug Plan in other situations. Drugs are never covered by both Part B and our plan at the same time. In general, your pharmacist or provider will determine whether to bill Medicare Part B or the COEHA Medicare Part D Prescription Drug Plan for the drug.

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 that tells if your prescription drug coverage is “creditable,” and the choices you have for drug coverage. (If the coverage from the Medigap policy is “creditable,” it means that it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) The notice will also explain how much your premium would be lowered if you remove the prescription drug coverage portion of your Medigap policy. If you didn’t get this notice, or if you can’t find it, contact your Medigap insurance company and ask for another copy.

Section 9.5 What if you’re also getting drug coverage from an employer or retiree group plan?

Do you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group? If so, please contact that group’s benefits administrator. He or she can help you determine how your current prescription drug coverage will work with our plan.

In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first.

Special note about ‘creditable coverage’:

Each year your employer or retiree group should send you a notice that tells if your prescription drug coverage for the next calendar year is “creditable” and the choices you have for drug coverage.

If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn’t get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from the employer or retiree group’s benefits administrator or the employer or union.

SECTION 10 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 your 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 provider to correct the problem.

Section 10.2 Programs to help members manage their medications

Informed RX has programs that can help our members with special situations. For example, some members have several complex medical conditions or they may need to take many drugs at the same time, or they could have very high drug costs.

These programs are voluntary and free to members. A team of pharmacists and doctors developed the programs for Informed RX. The programs can help make sure that our members are using the drugs that work best to treat their medical conditions and help Informed RX identify possible medication errors.

If Informed RX has a program that fits your needs, they will automatically enroll you in the program and send you information. If you decide not to participate, please notify them and they will withdraw you from the program. If you have any questions about these programs, please contact Informed RX Customer Service.

CHAPTER FOUR, SECTION 1

Introduction

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. 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 about the costs for Part D prescription drugs may not apply to you. We will send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider), which tells you about your drug coverage. If you don’t have this insert, please call COEHA Customer Service and ask for the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Phone numbers for COEHA Customer Service are on the inside front cover of this booklet.

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, not all drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law.

To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Here are materials that explain these basics:

The plan’s List of Covered Drugs (Formulary). To keep things simple, we call this the “Drug List.”

o This Drug List tells which drugs are covered for you.

It also tells which of the three “cost-sharing tiers” the drug is in and whether there are any restrictions on your coverage for the drug.

o If you need a copy of the Drug List, call Informed RX Customer Service at 1-866-443-1095. You can also find the Drug List on their website at http://www.myinformedrx.com or on our website at www.coeha.com. The Drug List on the website is always the most current.

	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 an Informed RX network pharmacy to get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list of pharmacies in the Informed RX network. 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 drug payment stages for COEHA Medicare Part D Prescription Drug Plan members?

As shown in the table below, there are “drug payment stages” for your prescription drug coverage under COEHA Medicare Part D Prescription Drug Plan. How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled. Keep in mind you are always responsible for the plan’s monthly premium regardless of the drug payment stage.

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.)	During this stage, 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 year-to-date “total drug costs” (your payments plus the plan’s payments) total $5000.00 (Details are in Section 5 of this chapter.)	During this stage, you pay 50% of the price (plus the dispensing fee) for brand name drugs and 86% of the price for generic drugs. You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $4700.00. This amount and rules for counting costs toward this amount have been set by Medicare. (Details are in Section 6 of this chapter.)	During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2012). (Details are in Section 7 of this chapter.)

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” (the “EOB”)

Informed RX keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug payment stage to the next. In particular, there are two types of costs they keep track of:

	They keep track of how much you have paid. This is called your “out-of-pocket” cost.
	They 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 through the plan during the previous month. 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 Informed RX 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 we know 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 Informed RX has the information they need. There are times you may pay for prescription drugs when Informed RX will not automatically get the information they need to keep track of your out-of-pocket costs. To help Informed RX keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. We will make sure Informed RX gets a record of these expenses. (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:

o When you purchase a covered drug at an Informed RX network pharmacy at a special price or using a discount card that is not part of our plan’s benefit.

o When you have made a copayment for drugs that are provided under a drug manufacturer patient assistance program.

o Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances.

Send us information about the payments others have made for you. Payments made by certain other individuals and organizations also count toward your out-of-pocket costs and help qualify you for catastrophic coverage. For example, payments made by a State Pharmaceutical Assistance Program, an AIDS drug assistance program, the Indian Health Service, and most charities count toward your out-of-pocket costs. You should keep a record of these payments and send them to us so we can track your costs.

Check the written report we send you. When you receive an Explanation of Benefits (an EOB) 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 front 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 2012.

Your “full cost” is usually lower than the normal full price of the drug, since Informed RX 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 copayment). Your share of the cost will vary depending on the drug and where you fill your prescription.

The plan has three Cost-Sharing Tiers

Every drug on the plan’s Drug List is in one of three cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug:

	Tier 1 is for generics. (This is the lowest cost tier.)
	Tier 2 is for preferred brand medications.
	Tier 3 is for “non-preferred” medications. These medications have a less expensive clinical alternative medication available on Tier 2. (This is the highest cost tier.)

To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List.

Your pharmacy choices

How much you pay for a drug depends on whether you get the drug from:

	A local retail pharmacy that is in the Informed RX network
	A pharmacy that is in the Informed RX network
	The Informed RX 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 one-month 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.

As shown in the table below, the amount of the copayment depends on which tier your drug is in. Please note:

	If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower.
	We cover prescriptions filled at out-of-network pharmacies in only limited situations. Please see Chapter 3, Section 2.5 for information about when we will cover a prescription filled at an out-of-network pharmacy.

Your share of the cost when you get a one-month supply (or less) of a covered Part D prescription drug from:

Tier	Informed RX Pharmacy (up to a 30-day supply)	Informed RX Mail-Order Service (up to a 30-day supply)	Informed RX Long-Term Care Pharmacy (up to a 30-day supply)	Out-of-Network Pharmacy (Coverage is limited to certain situations (see Chapter 3) (up to a 30-day supply)
Tier One Generic	$10.00	$10.00	$10.00	$10.00
Tier Two Preferred Brand	$35.00	$35.00	$35.00	$35.00
Tier Three Non-Preferred Brand (These medications have a less expensive clinical alternative medication available on Tier Two.)	$50.00	$50.00	$50.00	$50.00

Section 5.3 A table that shows your costs for a long-term: up to a 90-day supply of a drug

For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. A long-term supply is up to a 90-day supply. (For details on where and how to get a long-term supply of a drug, see Chapter 3, Section 2.4.)

The table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.

Please note: If your covered drug costs less than the copayment amount listed in the chart, you will pay that lower price for the drug. You pay either the full price of the drug or the copayment amount, whichever is lower.

Your share of the cost when you get a long-term supply of a covered Part D prescription drug from:

Tier	Informed RX Retail Pharmacy	Informed RX Mail-Order Service
Tier One Generic	$20.00	$20.00
Tier Two Preferred Brand	$70.00	$70.00
Tier Three Non-Preferred Brand (These medications have a less expensive clinical alternative medication available on Tier Two.)	$90.00	$90.00

Section 5.4 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 any Part D plan has paid:

· What you have paid for all the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare calculates your out-of-pocket costs.) This includes:

o The $150.00 you paid when you were in the Deductible Stage.

o The total you paid as your share of the cost for your drugs during the Initial Coverage Stage.

· What the plan has paid as its share of the cost for your drugs during the Initial Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2012, the amount that plan paid during the Initial Coverage Stage also counts toward your total drug costs.)

We also provide some over-the-counter medications exclusively for your use. These over-the-counter drugs are provided at no cost to you. To find out which drugs our plan covers, refer to your formulary.

The Explanation of Benefits (EOB) that we send to you will help you keep track of how much you and the plan have spent for your drugs during the year. Many people do not reach the $5000.00 limit in a year.

We will let you know if you reach this $5000.00 limit. If you do reach this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage.

SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 86% of the costs for generic drugs

Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $4700.00

When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 50% of the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) for brand name drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap.

You also receive some coverage for generic drugs. You pay no more than 86% of the cost for generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (14%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap.

You continue paying the discounted price for brand name drugs and no more than 86% of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2012, that amount is $4700.00.

Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $4700.00, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

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 3 of this booklet):

· The amount you pay for drugs when you are in any of the following drug payment stages:

o The Deductible Stage.

o The Initial Coverage Stage.

o The Coverage Gap Stage.

· Any payments you made during this calendar year as a member of a different 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, by AIDS drug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare’s “Extra Help” Program are also included.

· Some of the payments made by the Medicare Coverage Gap Discount Program are included. The amount the manufacturer pays for your brand name drugs is included, but the amount the plan pays for your generic drugs is not included.

Moving on to the Catastrophic Coverage Stage:

When you (or those paying on your behalf) have spent a total of $4700.00 in out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage.

These payments are not included in your out-of-pocket costs

When you add up your out-of-pocket costs, you are not allowed to include any of these types of payments for prescription drugs:

· The amount you pay for your monthly premium.

· Drugs you buy outside the United States and its territories.

· Drugs that are not covered by our plan.

· Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements for out-of-network coverage.

· Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from coverage by Medicare.

· Prescription drugs covered by Part A or Part B.

· Payments made by the plan for your generic drugs while in the Coverage Gap.

· Payments for your drugs that are made by group health plans including employer health plans.

· Payments for your drugs that are made by certain insurance plans and government-funded health programs such as TRICARE and the Veteran’s Administration.

· Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Worker’s Compensation).

Reminder: If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for drugs, you are required to tell our plan. Call COEHA Customer Service to let us know (phone numbers are on the inside front cover of this booklet).

How can you keep track of your out-of-pocket total?

· Informed RX will help you. The Explanation of Benefits (EOB) report we send to you, upon request, includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $4700.00 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage.

· Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date.

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 $4700.00 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.

During this stage, the plan will pay most of the cost for your drugs.

Your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is the larger amount:

o –either – coinsurance of 5% of the cost of the drug

o –or – $2.60 copayment for a generic drug or a drug that is treated like a generic. Or a $6.50 copayment for all other drugs.

Our plan pays the rest of the cost.

SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them

Section 8.1 Our plan has separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccination shot

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of vaccinations:

	The first part of coverage is the cost of the vaccine medication 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 Part D vaccination?

What you pay for a Part D vaccination depends on three things:

1. The type of vaccine (what you are being vaccinated for).

	Some vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s List of Covered Drugs (Formulary).
	Other vaccines are considered medical benefits. They are covered under Original Medicare.

2. Where you get the vaccine medication.

3. Who gives you the vaccination shot.

What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For 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 Part D vaccination shot. Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Deductible Stage and Coverage Gap Stage of your benefit.

Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.)

· You will have to pay the pharmacy the amount of your copayment for the vaccine and administration of the vaccine.

Situation 2: You get the Part D vaccination at your doctor’s office.

· When you get the vaccination, you will pay for the entire cost of the vaccine and its administration.

· You can then ask our plan to pay our share of the cost by using the procedures that are described in Chapter 5 of this booklet (Asking us to pay our share of the costs for covered drugs).

· You will be reimbursed the amount you paid less your normal coinsurance for the vaccine (including administration) less any difference between the amount the doctor charges and what we normally pay. (If you get Extra Help, we will reimburse you for this difference.)

Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot.

· You will have to pay the pharmacy the amount of your copayment for the vaccine itself.

· When your doctor gives you the vaccination shot, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 5 of this booklet.

· You will be reimbursed the amount charged by the doctor for administering the vaccine less any difference between the amount the doctor charges and what we normally pay. (If you get Extra Help, we will reimburse you for this difference.)

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 front 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 and the Informed RX 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”?

Note: If you receive “Extra Help” from Medicare to pay for your prescription drugs, the late enrollment penalty rules do not apply to you. You will not pay a late enrollment penalty, even if you go without “creditable” prescription drug coverage.

You may pay a financial penalty if you did not enroll in a plan offering Medicare Part D drug coverage when you first became eligible for this drug coverage or you experienced a continuous period of 63 days or more when you didn’t have creditable prescription drug coverage. (“Creditable prescription drug coverage” is coverage that meets Medicare’s minimum standards since it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) The amount of the penalty depends on how long you waited to enroll in a creditable prescription drug coverage plan any time after the end of your initial enrollment period or how many full calendar months you went without creditable prescription drug coverage.

When you first enroll in the COEHA Medicare Part D Prescription Drug Plan, we let you know the amount of the penalty. We will bill you for this penalty twice every year in June and December.

Your late enrollment penalty is considered part of your plan premium. If you do not pay your late enrollment penalty, you could be disenrolled for failure to pay your plan premium.

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. You can also count the number of full months in which you did not have creditable prescription drug coverage, if the break in coverage was 63 days or more. The penalty is 1% for every month that you didn’t have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%.

	Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2012, this average premium amount is $31.08.
	To get your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here it would be 14% times $31.08, which equals $4.36. This rounds to $4.40. 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 aging into Medicare.

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:

If you already have prescription drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. Medicare calls this “creditable drug coverage.” Please note:

Creditable coverage could include drug coverage from a former employer or union, TRICARE, or the Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if your drug coverage is creditable coverage. This information may be sent to you in a letter or included in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later.

Please note: If you receive a “certificate of creditable coverage” when your health coverage ends, it may not mean your prescription drug coverage was creditable. The notice must state that you had “creditable” prescription drug coverage that is expected to pay as much as Medicare’s standard prescription drug plan pays.

The following are not creditable prescription drug coverage: prescription drug discount cards, free clinics, and drug discount websites.

For additional information about creditable coverage, please look in your Medicare & You 2012 Handbook or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

If you were without creditable coverage, but you were without it for less than 63 days in a row.

If you are receiving “Extra Help” from Medicare.

Section 9.4 What can you do if you disagree about your late enrollment penalty?

If you disagree about your late enrollment penalty, you or your representative can ask for a review of the decision about your late enrollment penalty. Generally, you must request this review within 60 days from the date on the letter you receive stating you have to pay a late enrollment penalty. Call COEHA Customer Service at the number on the front inside cover of this booklet to find out more about how to do this.

Important: Do not stop paying your late enrollment penalty while you’re waiting for a review of the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to pay your plan premiums.

SECTION 10 Do you have to pay an extra Part D amount because of your income?

Section 10.1 Who pays an extra Part D amount because of income?

Most people pay a standard monthly Part D premium. However, some people pay an extra amount because of their yearly income. If your income is $85,000 or above for an individual (or married individuals filing separately) or $170,000 or above for married couples, you must pay an extra amount for your Medicare Part D coverage.

If you have to pay an extra amount, the Social Security Administration, not your Medicare plan, will send you a letter telling you what that extra amount will be and how to pay it. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefit check, no matter how you usually pay your plan premium, unless your monthly benefit isn’t enough to cover the extra amount owed. If your benefit check isn’t enough to cover the extra amount, you will get a bill from Medicare. The extra amount must be paid separately and cannot be paid with your monthly plan premium.

Section 10.2 How much is the extra Part D amount?

If your modified adjusted gross income as reported on your IRS tax return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium.

Section 10.3 What can you do if you disagree about paying an extra Part D amount?

If you disagree about paying an extra amount because of your income, you can ask the Social Security Administration to review the decision. To find out more about how to do this, contact the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778).

COEHA 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/TTD	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, 2^nd Floor Clifton Forge, VA 24422 Coeha1@aol.com
WEBSITE	www.coeha.com

Coverage Decisions, Appeals and Complaints for Part D Prescription Drugs
CALL	1-800-679-9135 or local residents in the Clifton Forge, VA area call 862-5728 Calls to these numbers are free. Our hours of operation are Monday through Friday, 8:30 am to 5:00 pm (EST)
TTY/TTD	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, 2^nd Floor Clifton Forge, VA 24422 Coeha1@aol.com
WEBSITE	www.coeha.com

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/TTD	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, 2^nd Floor Clifton Forge, VA 24422
WEBSITE	www.coeha.com

	Your copy of Medicare & You 2012 gives information about these premiums in the section called “2012 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 also download a copy of Medicare & You 2012 from the Medicare website (http://www.medicare.gov). You can 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.

	If you have retiree coverage, Medicare pays first.
	If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the size of the employer, and whether you have Medicare based on age, disability, or End-stage Renal Disease (ESRD):

	If you’re under 65 and disabled and you or your family member is still working, your plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan has more than 100 employees.
	If you’re over 65 and you or your spouse is still working, the plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan has more than 20 employees.

	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 our share of the cost to you. (Chapter 3 explains the rules you need to follow for getting your Part D prescription drugs covered.) Informed RX will send payment within 30 days after your request was received.
	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.

	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

	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.

	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.

	For example, you have the right to get information from us about the pharmacies in the Informed RX network.
	For a list of the pharmacies in the plan’s 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 http://www.myinformedrx.com or visit our website at www.coeha.com.

	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 (Formulary), 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 front inside cover of this booklet).

	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. You can ask us to change the decision by making an appeal. 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 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.

	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.

	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 front 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 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.

This list of chapters and page numbers is just your starting point. For more help in finding information you need, go to the first page of a chapter. For your reference, we are listing the first page of each chapter.