C and O Employees' Hospital Association
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C and O Employees' Hospital Association
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Link to the CMS Best Available Evidence home page: http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp#TopOfPage COEHA
1897 2009 Evidence of Coverage (EOC)
10. How Much you Pay for Your Part D Prescription Drugs
Introduction Thank you for being a member of our Plan! This is your Evidence of Coverage, which explains how to get your Medicare drug coverage through our Plan, an Employer/Union Medicare Part D Prescription Drug Plan. This Evidence of Coverage, together with your enrollment form, riders, and amendments that we send to you, is our contract with you. The Evidence of Coverage explains your rights, benefits, and responsibilities as a member of our Plan and is in effect from January 1, 2009 - December 31, 2009. Our Plan’s contract with the Centers for Medicare & Medicaid Services (CMS) is renewed annually, and availability of coverage beyond the end of the current contract year is not guaranteed. This Evidence of Coverage will explain to you:
This Section of the EOC has important information about:
Eligibility Requirements To be a member of our Plan, you must be enrolled in the Original Medicare Plan, Parts A and B. If you currently pay a premium for Medicare Part A and/or Medicare Part B, you must continue paying your premium in order to keep your Medicare Part A and/or Medicare Part B and remain a member of this Plan and also fall in one of the following categories:
The geographic service area for our Plan. Your coverage is portable—you will never lose coverage by moving to a different state within the United States. How do I keep my membership record up to date? We have a membership record about you. Your membership record has information from your enrollment form, including your address and telephone number. Pharmacists and others use your membership record to know what drugs are covered for you. Section 3 tells how we protect the privacy of your personal health information. Please help us keep your membership record up to date by telling COEHA Customer Service if there are changes to your name, address, or phone number, or if you go into a nursing home. Also, tell COEHA Customer Service about any changes in other health insurance coverage you have, such as from your employer, your spouse’s employer, workers’ compensation, Medicaid, or liability claims such as claims from an automobile accident. Materials that you will receive from our Plan Plan membership card Now that you are a member of our Plan, your membership card for prescription drug coverage is from National Medical Health Card Systems, Inc. ("NMHC RX"). You must use your membership card for prescription drug coverage at network pharmacies. You may need to continue to use your red, white, and blue Medicare card to get covered services and items under Original Medicare. Please carry your NMHC RX membership card at all times and remember to show your card when you get covered prescription drugs. If your membership card is damaged, lost, or stolen, call NMHC RX Customer Service right away and they will send you a new card. There is a sample card in Section 10 to show you what it looks like. The Pharmacy Directory gives you a list of Plan network pharmacies. As a member of our Plan, NMHC RX will send you a Pharmacy Directory, which gives you a list of their main network pharmacies, at least every three years. You can use it to find the network pharmacy closest to you. If you don’t have the Pharmacy Directory, you can get a copy from NMHC RX Customer Service. They can also give you the most up-to-date information about changes in their pharmacy network, which can change during the year. You can also find this information on their web site, www.nmhcrx.com.Part D Explanation of Benefits What is the Explanation of Benefits? The Explanation of Benefits ("EOB") is a document you can request from us. The EOB will tell you the total amount you have spent on your prescription drugs and the total amount we have paid for your prescription drugs. What information is included in the Explanation of Benefits? Your Explanation of Benefits will contain the following information:
As a member of our Plan, you pay a monthly plan premium which includes payment for your membership in the COEHA Supplemental Plan. (If you qualify for extra help from Medicare, called the Low-Income Subsidy or LIS, you may not have to pay for part of the monthly premium) Your monthly premium for our Plan is listed in the 2009 COEHA Medicare Part D Prescription Drug Plan Annual Notice of Change. If you get benefits from your current or former employer, or from your spouse’s current or former employer, call the employer’s benefits administrator for information about your monthly plan premium. Note: If you are getting extra help (LIS) with paying for your drug coverage, the premium amount that you pay as a member of this Plan is listed in your "Evidence of Coverage Rider for those who Receive Extra Help for their Prescription Drugs". If you are a member of a State Pharmacy Assistance Program (SPAP), you may get help paying your premiums. Please contact your SPAP to determine what benefits are available to you." Monthly Plan Premium Payment Options There are two ways to pay your monthly plan premium.
Option one: Pay your plan premium directly to COEHA You may decide to pay your monthly plan premium directly to COEHA quarterly, semi-annually or annually. Your check should be mailed to the following address, or if you are local, you can drop off the check in person: C and O Employees’ Hospital Association 511 Main Street, 2nd Floor Clifton Forge, VA 24422
Option two: Automatic dues deductions Instead of paying by check, you can have your monthly plan premium automatically withdrawn from your bank account on the fifth (5th) day of each month. To initially set up one of the above options, refer to page four of your COEHA Supplemental Enrollment Form, under Section entitled "PAYMENT OPTION". Please select Option A or B. To change your existing method of payment, request and complete a "COEHA METHOD OF PAYMENT FORM". Can your monthly plan premiums change during the year? What is the Medicare Prescription Drug Plan late enrollment penalty? If you don’t join a Medicare drug plan when you are first eligible, and/or you go without creditable prescription drug coverage for a continuous period of 63 days or more, you may have to pay a late enrollment penalty when you enroll in a plan later. The Medicare drug plan will let you know what the amount is and it will be added to your monthly premium. This penalty amount changes every year, and you have to pay it as long as you have Medicare prescription drug coverage. However, if you qualified for extra help in 2006, 2007, or 2008, you may not have to pay a penalty. If you must pay a late enrollment penalty, your penalty is calculated when you first join a Medicare drug plan. To estimate your penalty, take 1% of the national base beneficiary premium for the year you join (in 2008, the national base beneficiary premium is $27.93. This amount may change in 2009)". Multiply it by the number of full months you were eligible to join a Medicare drug plan but didn’t, and then round that amount to the nearest ten cents. This is your estimated penalty amount, which is added each month to your Medicare drug plan’s premium for as long as you are in that plan. If you disagree with your late enrollment penalty, you may be eligible to have it reconsidered (reviewed). Call COEHA Customer Service to find out more about the late enrollment penalty reconsideration process and how to ask for such a review. You won’t have to pay a late enrollment penalty if:
What happens if you don’t pay or are late with your monthly plan premiums? If your monthly plan premiums are late, we will tell you in writing that if you don’t pay your monthly plan premium by a certain date, which includes a grace period, we will end your membership in our Plan. Our Plan’s grace period is 90 days. Should you decide later to re-enroll in our Plan, or to enroll in another plan that we offer, you will have to pay any late monthly plan premiums that you didn’t pay from your previous enrollment in our Plan. What extra help is available to help pay my plan costs? 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 will get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription co-payments. If you qualify, this extra help will count toward your out-of-pocket costs.Do you qualify for extra help? People with limited income and resources may qualify for extra help one of two ways. The amount of extra help you get will depend on your income and resources.
How do costs change when you qualify for extra help? If you qualify for extra help, we will send you by mail an "Evidence of Coverage Rider for those who Receive Extra Help Paying for their Prescription Drugs" that explains your costs as a member of our Plan. If the amount of your extra help changes during the year, we will also mail you an updated "Evidence of Coverage Rider for those who Receive Extra Help Paying for their Prescription Drugs". What if you believe you have qualified for extra help and you believe that you are paying an incorrect co-payment amount? If you believe you have qualified for extra help and you believe that you are paying an incorrect co-payment amount when you get your prescription at a pharmacy, our Plan has established a process that will allow 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. You should contact COEHA Customer Service and we will work with you on establishing your correct LIS status. We will also make sure NMHC RX has your correct status. When we receive the evidence showing your co-payment level, we will update our system and have NMHC RX update their system or implement other procedures so that you can pay the correct co-payment when you get your next prescription at the pharmacy. Please be assured that if you overpay your co-payment, NMHC RX will reimburse you. Either they will forward a check to you in the amount of your overpayment or they will offset future co-payments. Of course, if the pharmacy hasn’t collected a co-payment from you and is carrying your co-payment as a debt owed by you, they will make the payment directly to the pharmacy. If a state paid on your behalf, they may make payment directly to the state. Please contact COEHA Customer Service if you have questions. Important Information We will send you a Coordination of Benefits Survey or call you so that we can know what other drug coverage you have besides our Plan. Medicare requires us to collect this information from you, so when you get the survey, please fill it out and send it back. If you have additional drug coverage, you must provide that information to our Plan. The information you provide helps us calculate how much you and others have paid for your prescription drugs. In addition, if you lose or gain additional prescription drug coverage, please call COEHA Customer Service to update your membership records. 2. How You Get Prescription Drugs What do you pay for covered drugs? The amount you pay for covered drugs is listed in Section 10. If you have Medicare and Medicaid Medicare, not Medicaid, will pay for most of your prescription drugs. You will continue to get your health coverage under both Medicare and Medicaid as long as you qualify for Medicaid benefits. If you are a member of a State Pharmacy Assistance Program (SPAP) What drugs are covered by this Plan? What is a formulary? A formulary is a list of the drugs that we cover. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an NMHC RX network pharmacy or through NMHC RX network mail-order pharmacy and other coverage rules are followed. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits are described later in this section under "Utilization Management." The drugs on the formulary are selected by our Plan with the help of a team of health care providers. Both brand-name drugs and generic drugs are included on the formulary. A generic drug is a prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Not all drugs are covered by our Plan. In some cases, the law prohibits Medicare coverage of certain types of drugs. (See Section 10 for more information about the types of drugs that are not normally covered under a Medicare Prescription Drug Plan.) In other cases, we have decided not to include a particular drug on our formulary. In certain situations, prescriptions filled at an out-of-network pharmacy may also be covered. See information later in this section about filling a prescription at an out-of-network pharmacy. How do you find out what drugs are on the formulary? You may call NMHC RX Customer Service to find out if your drug is on the formulary or to request a copy of our formulary. You can get updated information about the drugs our Plan covers by visiting our Website. Can the formulary change? We may make certain changes to our formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. The kinds of formulary changes we may make include:
If we remove drugs from the formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug, and you are taking the drug affected by the change, you will be permitted to continue taking that drug at the same level of cost-sharing for the remainder of the Plan year. However, if a brand name drug is replaced with a new generic drug, or our formulary is changed as a result of new information on a drug’s safety or effectiveness, you may be affected by this change. We will notify you of the change at least 60 days before the date that the change becomes effective or provide you with a 60 day supply at the pharmacy. This will give you an opportunity to work with your physician to switch to a different drug that we cover or request an exception. (If a drug is removed from our formulary because the drug has been recalled from the pharmacies, we will not give 60 days notice before removing the drug from the formulary. Instead, we will remove the drug immediately and notify members taking the drug about the change as soon as possible.) What if your drug isn’t on the formulary? If your prescription isn’t listed on the formulary, you should first contact COEHA Customer Service to be sure it isn’t covered. If COEHA Customer Service confirms that we don’t cover your drug, you have two options:
In some cases, we will contact you if you are taking a drug that isn’t on our formulary. We can give you the names of covered drugs that also are used to treat your condition so you can ask your doctor if any of these drugs are an option for your treatment. If you recently joined this Plan, you may be able to get a temporary supply of a drug you were taking when you joined our Plan if it isn’t on our formulary. Transition Policy New members in our Plan may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 under "What is an exception?" to learn more about how to request an exception. Please contact COEHA Customer Service if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception. During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary 30-day supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year. When a new member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at an NMHC RX network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Section 10 for information about non-Part D drugs. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. The requirements for coverage or limits on certain drugs are listed as follows: Prior Authorization: We require you to get prior authorization (prior approval) for certain drugs. This means that your provider will need to contact us before you fill your prescription. If we don’t get the necessary information to satisfy the prior authorization, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 1 pill per day per prescription of Celebrex. Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. Generic Substitution: You must pay the difference in price when you get a name brand medication filled and there is a generic available. NMHC RX network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug and we have approved this request. You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary on our website or by calling COEHA Customer Service. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination). See Section 5 for more information about how to request an exception. NMHC RX conducts drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. NMHC RX conducts drug utilization reviews each time you fill a prescription and on a regular basis by reviewing your records. During these reviews, they look for medication problems such as:
If NMHC RX identifies a medication problem during their drug utilization review, they will work with your doctor to correct the problem. Medication therapy management programs NMHC RX offers medication therapy management programs at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. NMHC RX uses these medication therapy management programs to help us provide better coverage for our members. For example, these programs help NMHC RX make sure that our members are using appropriate drugs to treat their medical conditions and help them identify possible medication errors. NMHC RX may contact members who qualify for these programs. If they contact you, we hope you will join so that they can help you manage your medications. Remember, you don’t need to pay anything extra to participate. If you are selected to join a medication therapy management program, NMHC RX will send you information about the specific program, including information about how to access the program. Your enrollment in this Plan doesn’t affect Medicare 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, it can’t be covered by us (through Medicare Part D) even if you choose not to participate in Part A or Part B. Some drugs may be covered under Medicare Part B in some cases and through this Plan (Medicare Part D) in other cases but never both at the same time. In general, your pharmacist or provider will determine whether to bill Medicare Part B or us for the drug in question. See your Medicare & You Handbook for more information about drugs that are covered by Medicare Part A and Part B. The Medicare & You Handbook can also be found on www.medicare.gov or you can request a copy by 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 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 (prior to November 15), your Medigap insurance company must send you a letter explaining your options and whether the prescription drug coverage you have is creditable (whether it expects to pay, on average, at least as much as Medicare’s standard prescription drug coverage). If you didn’t get this letter or can’t find it, you have the right to get a copy from your Medigap insurance company. If you are a member of an employer or retiree group If you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group, please contact your benefits administrator to determine how your current prescription drug coverage will work with this 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. Each year (prior to November 15), your employer or retiree group should provide a disclosure notice to you that indicates if your prescription drug coverage is creditable (meaning it expects to pay, on average, at least as much as Medicare’s standard prescription drug coverage) and the options available to you. You should keep the disclosure notices that you get each year in your personal records to present to a Part D plan when you enroll to show that you have maintained creditable coverage. If you didn’t get this disclosure notice, you may get a copy from the employer’s or retiree group’s benefits administrator or employer/union. Using network pharmacies to get your prescription drugs With few exceptions, which are noted later in this section under "How do you fill prescriptions outside the network?", you must use network pharmacies to get your prescription drugs covered. A network pharmacy is a pharmacy that has a contract with NMHC RX to provide your covered prescription drugs. The term "covered drugs" means all of the outpatient prescription drugs that are covered by our Plan. Covered drugs are listed in our formulary. In most cases, your prescriptions are covered only if they are filled at one of the NMHC RX network pharmacies. You aren’t required to always go to the same pharmacy to fill your prescription; you may go to any of the NMHC RX network pharmacies. However, if you switch to a different network pharmacy than the one you have previously used, you must either have a new prescription written by a doctor or have the previous pharmacy transfer the existing prescription to the new pharmacy if any refills remain. To find an NMHC RX network pharmacy in your area, please review your Pharmacy Directory or call NMHC RX Customer Service. What if a pharmacy is no longer a network pharmacy? Sometimes a pharmacy might leave the NMHC RX network. If this happens, you will have to get your prescriptions filled at another NMHC RX network pharmacy. Please refer to your Pharmacy Directory or call NMHC RX Customer Service to find another network pharmacy in your area. How do you fill a prescription at a network pharmacy? To fill your prescription, you must show your Plan membership card at one of our network pharmacies. If you don’t have your membership card with you when you fill your prescription, you may have the pharmacy call COEHA Customer Service at 1-800-679-9135 or local pharmacies in the Clifton Forge, VA area call 862-5728 to obtain the necessary information. If the pharmacy is unable to obtain the necessary information, you may have to pay the full cost of the prescription. If you pay the full cost of the prescription (rather than paying just your co-payment) you may ask us to reimburse you for our share of the cost by submitting a claim to us. To learn how to submit a paper claim, please refer to the paper claims process described in the subsection below called "How do you submit a paper claim?" How do you fill a prescription through our Plan’s network mail-order-pharmacy service? When you order prescription drugs through the NMHC RX network mail-order-pharmacy service, you must order a 90-day supply of the drug. Generally, it takes the mail-order pharmacy 14 days to process your order and ship it to you. However, sometimes your mail-order may be delayed. You should call NMHC RX or COEHA Customer Service if your mail-order is delayed. You are not required to use mail-order prescription drug services to obtain an extended supply (90-day fill) of medications. Instead, you have the option of using some retail pharmacies for an extended supply. Some of these retail pharmacies have agreed to accept the mail-order co-payment for an extended supply of medications, which will result in no out-of-pocket payment difference to you. (All Walmart, Kroger, Rite Aid and Target Pharmacies will handle 90-day fills for mail-order co-payments.) Other retail pharmacies may not agree to accept the mail-order co-payments for an extended supply of medications. In this case, you will be responsible for the difference in price. Please call NMHC RX Customer Service to find out which other retail pharmacies participate in a 90-day fill for a mail-order co-payment. To get order forms and information about filling your prescriptions by mail, please call NMHC RX or COEHA Customer Service. Please note that you must use NMHC RX network mail-order service. Prescription drugs that you get through any other mail-order services are not covered. How do you fill prescriptions outside the network? We only cover drugs filled at an out-of-network pharmacy under emergency circumstances which would not permit access to an NMHC RX network pharmacy. Before you fill your prescription in this situation, call NMHC RX Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy, you may have to pay the full cost rather than paying just your co-payment when you fill your prescription. You may ask us to reimburse you for our share of the cost by submitting a paper claim. You should submit a claim to NMHC RX if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described in the subsection below called "How do you submit a paper claim?" If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy. How do you submit a paper claim? You may submit a paper claim for reimbursement of your drug expenses in the situations described below:
You may ask us to reimburse you for our share of the cost of the prescription by calling COEHA Customer Service and requesting a Member Reimbursement Prescription Claim Form. Please mail your written reimbursement request to the address listed under Part D Reimbursement Requests in Section 8. Please include your receipt(s) with your written request. How does your prescription drug coverage work if you go to a hospital or skilled nursing facility? If you are admitted to a hospital for a Medicare-covered stay, Medicare Part A should generally cover the cost of your prescription drugs while you are in the hospital. Once you are released from the hospital, we will cover your prescription drugs as long as the drugs meet all of our coverage requirements (such as that the drugs are on our formulary, filled at a network pharmacy, and they aren’t covered by Medicare Part A or Part B.) We will also cover your prescription drugs if they are approved under the Part D coverage determination, exceptions, or appeals process. Long-term care (LTC) pharmacies Generally, residents of a long-term-care facility (like a nursing home) may get their prescription drugs through the facility’s LTC pharmacy or another network LTC pharmacy. Please refer to your Pharmacy Directory to find out if your LTC pharmacy is part of our network. If it isn’t, or for more information, contact NMHC RX Customer Service. Please refer to your Pharmacy Directory to find a home infusion pharmacy provider in your area. For more information, contact NMHC RX Customer Service.Some vaccines and drugs may be administered in your doctor’s office We may cover vaccines that are preventive in nature and aren’t already covered by Medicare Part B. This coverage includes the cost of vaccine administration. See Section 10 for more information about your costs for covered vaccinations. 3. Your Rights and Responsibilities as a Member of our Plan Introduction to your rights and protections Since you have Medicare, you have certain rights to help protect you. In this section, we explain your Medicare rights and protections as a member of our Plan and we explain what you can do if you think you are being treated unfairly or your rights are not being respected. Your right to be treated with dignity, respect and fairness You have the right to be treated with dignity, respect, and fairness at all times. Our Plan must obey laws that protect you from discrimination or unfair treatment. We don’t discriminate based on a person’s race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age, or national origin. COEHA Customer Service can also help if you need to file a complaint about access (such as wheelchair access). You may also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697, or your local Office for Civil Rights. Your right to the privacy of your medical records and personal health information There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal information that you give us when you enroll in this plan is protected. We will make sure that unauthorized people don’t see or change your records. Generally, we must get written permission from you (or from someone you have given legal power to make decisions for you) before we can give your health information to anyone who isn’t providing your care or paying for your care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care. The Plan will release your information, including your prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable Federal statutes and regulations. The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We are required to provide you with a notice that tells about these rights and explains how we protect the privacy of your health information. You have the right to look at medical records held at the Plan, and to get a copy of your records (there may be a fee charged for making copies). You also have the right to ask us to make additions or corrections to your medical records (if you ask us to do this, we will review your request and figure out whether the changes are appropriate). You have the right to know how your health information has been given out and used for non-routine purposes. If you have questions or concerns about privacy of your personal information and medical records, please call COEHA Customer Service. You have the right to timely access to your prescriptions at any network pharmacy Your right to use advance directives (such as a living will or a power of attorney) You have the right to ask someone such as a family member or friend to help you with decisions about your health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. You also have the right to give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called "advance directives." There are different types of advance directives and different names for them. Documents called "living will" and "power of attorney for health care" are examples of advance directives. If you want to have an advance directive, you can get a form from us, 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. 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. It is important to sign this form and keep a copy at home. 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. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. If you have signed an advance directive, and you believe that a doctor or hospital hasn’t followed the instructions in it, you may file a complaint with the appropriate state agency. Your right to get information about our Plan You have the right to get information from us about our Plan. This includes information about our financial condition, and how our Plan compares to other health plans. To get any of this information, call COEHA Customer Service. Your right to get information about NMHC RX network pharmacies You have the right to get information from us or NMHC RX about their network pharmacies. To get this information, call COEHA Customer Service or NMHC RX Customer Service. Your right to get information about your prescription drugs and costsYou have the right to an explanation from us about any prescription drugs not covered by our Plan. We must tell you in writing why we will not pay for or approve a prescription drug, and how you can file an appeal to ask us to change this decision. See Section 5 for more information about filing an appeal. You also have the right to this explanation even if you obtain the prescription drug from a pharmacy not affiliated with our organization. You also have the right to receive an explanation from us about any utilization-management requirements, such as step therapy or prior authorization, which may apply to your Plan. Please review our formulary website or call COEHA Customer Service for more information. Your right to make complaints You have the right to make a complaint if you have concerns or problems related to your coverage. See Section 4 and Section 5 for more information about complaints. If you make a complaint, we must treat you fairly (i.e., not retaliate against you) because you made a complaint. You have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, call COEHA Customer Service. How to get more information about your rights If you have questions or concerns about your rights and protections, you can
What can you do if you think you have been treated unfairly or your rights are not being respected? If you think you have been treated unfairly or your rights have not been respected, you may call COEHA Customer Service or:
Your responsibilities as a member of our Plan include:
A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in Section 5 of this manual. Grievances do not involve problems related to approving or paying for Part D drugs. If we will not pay for or give you the Part D drugs you want, you must follow the rules outlined in Section 5. What types of problems might lead to your filing a grievance?
If you have one of these types of problems and want to make a complaint, it is called "filing a grievance." You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call COEHA Customer Service. Filing a grievance with our Plan If you have a complaint, you or your representative may call the phone number for Part D Grievances (for complaints about Part D drugs) in Section 8. We will try to resolve your complaint over the phone. If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this "Formal Grievance Procedure" and it is described below. Formal Grievance Procedure Filing of a Grievance: If you have a complaint involving something other than a request for coverage determination or an appeal, you may file a written grievance with the Administrator of COEHA within 60 days of the event underlying the complaint. The written grievance must include your name, COEHA identification number, address and a full explanation of your complaint, including specific dates, persons, places and events relevant to your complaint. Please include supporting documentation; if any, when filing your written grievance. Internal Committee Review: After your written grievance is received, the Administrator will review your grievance for completeness. If the Administrator does not think the grievance is complete, he can request additional information from you. Once the Administrator deems your grievance complete, he will refer your grievance to an Internal Committee of three to five COEHA administrative staff members appointed by the Administrator. The Internal Committee will review your complaint and make a decision within 30 days of receiving your complaint. The decision will be set forth in writing with the Internal Committee’s findings and resolution of the complaint. Finance Committee Review: If you do not agree with the Internal Committee’s decision, you may request that it be reviewed by the Finance Committee of the COEHA Board of Directors. To do so, you must submit a written request for Finance Committee review to the Administrator within 10 days of receiving the Internal Committee’s decision. The Administrator will then forward your grievance to the Finance Committee for review. The Finance Committee will review the grievance file and make a decision within 30 days of receiving the grievance file. The written decision will state whether the Finance Committee approves or disapproves the Internal Committee’s decision, and, if appropriate, will set forth the Finance Committee’s findings and resolution of the complaint. Decisions of the Finance Committee are final. The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have. Fast Grievances In certain cases, you have the right to ask for a "fast grievance," meaning we will answer your grievance within 24 hours. We discuss situations where you may request a fast grievance in Section 5. For quality of care problems, you may also complain to the QIO You may complain about the quality of care received under Medicare. You may complain to us using the grievance process, to the Quality Improvement Organization (QIO), or both. If you file with the QIO, we must help the QIO resolve the complaint. See Section 8 for more information about the QIO in your state. 5. Complaints and Appeals about your Part D Prescription Drug(s) This section explains how you ask for coverage of your Part D drug(s) or payments in different situations. These types of requests and complaints are discussed below in Part 1. Other complaints that do not involve the types of requests or complaints discussed below in Part 1 are considered grievances. You would file a grievance if you have any type of problem with us or one of the NMHC RX network pharmacies that does not relate to coverage for Part D drugs. For more information about grievances, see Section 4. PART 1. Requests for Part D drugs If you have problems getting the Part D drugs you need, or payment for a Part D drug you already received, you must request an initial determination with the Plan. Initial Determinations The initial determination we make is the starting point for dealing with requests you may have about covering a Part D drug you need, or paying for a Part D drug you already received. Initial decisions about Part D drugs are called "coverage determinations." With this decision, we explain whether we will provide the Part D drug you are requesting, or pay for the Part D drug you already received. The following are examples of requests for initial determinations:
What is an exception? An exception is a type of initial determination (also called a "coverage determination") involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.
Generally, we will only approve your request for an exception if the alternative Part D drugs included on the Plan formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request. If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision. Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug. You may call us at the phone number shown under Part D Coverage Determinations in Section 8 to ask for any of these requests. Who may ask for an initial determination? You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your "appointed representative." You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative. If you are requesting Part D drugs, this statement must be sent to us at the address or fax number listed under "Part D Coverage Determinations" To learn how to name your appointed representative, you may call COEHA Customer Service. You also have the right to have a lawyer act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. Asking for a "standard" or "fast" initial determination A decision about whether we will give you, or pay for, the Part D drug you are requesting can be a "standard" decision that is made within the standard time frame, or it can be a "fast" decision that is made more quickly. A fast decision is also called an "expedited" decision. Asking for a standard decision To ask for a standard decision for a Part D drug you, your doctor, or your representative should call, fax, or write us at the numbers or address listed under Part D Coverage Determinations (for appeals about Part D drugs) in Section 8. Asking for a fast decision You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a benefit that you already received.) If you are requesting a Part D drug that you have not yet received, you, your doctor, or your representative may ask us to give you a fast decision by calling, faxing, or writing us at the numbers or address listed under Part D Coverage Determinations (for appeals about Part D drugs in Section 8. Be sure to ask for a "fast," or "expedited" review. If your doctor asks for a fast decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision. If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "fast grievance." You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review (for more information about fast grievances, see Section 4). If we deny your request for a fast initial determination, we will give you a standard decision. What happens when you request an initial determination?
Generally, we must give you our decision no later than 72 hours after we receive your request, but we will make it sooner if your request is for a Part D drug that you have not received yet and your health condition requires us to. However, if your request involves a request for an exception (including a formulary exception, or an exception from utilization management rules – such as prior authorization, dosage limits, quantity limits, or step therapy requirements, we must give you our decision no later than 72 hours after we receive your physician's "supporting statement" explaining why the drug you are asking for is medically necessary. If you have not received an answer from us within 72 hours after we receive your request (or your physician's supporting statement if your request involves an exception), your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
What happens if we decide against you? If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision. (See Appeal Level 1.) Appeal Level 1: Appeal to the Plan You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan "redetermination." When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look. Who may file your appeal of the initial determination? If you are appealing an initial decision about a Part D drug, you or your representative may file a standard appeal request, or you, your representative, or your doctor may file a fast appeal request. Please see "Who may ask for an initial determination?" for information about appointing a representative. How soon must you file your appeal? You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline. 1. Asking for a standard appeal To ask for a standard appeal about a Part D drug a signed, written appeal request must be sent to the address listed under Part D Appeals (for appeals about Part D drugs) in Section 8. You may also ask for a standard appeal by calling us at the phone number shown under Part D Appeals (for appeals about Part D drugs) in Section 8. If you are appealing a decision we made about giving you a Part D drug that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules about asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling, faxing, or writing us at the numbers or address listed under Part D Appeals (for appeals about Part D drugs) in Section 8. Be sure to ask for a "fast" or "expedited" review. Remember, if your doctor provides a written or oral supporting statement explaining that you need the fast appeal, we will automatically give you a fast appeal. If you ask for a fast decision without support from a doctor, we will decide if your health requires a fast decision. If we decide that your medical condition does not meet the requirements for a fast decision, we will send you a letter informing you that if you get a doctor’s support for a fast review, we will automatically give you a fast decision. The letter will also tell you how to file a "fast grievance." You have the right to file a fast grievance if you disagree with our decision to deny your request for a fast review (for more information about fast grievances, see Section 4). If we deny your request for a fast appeal, we will give you a standard appeal. Getting information to support your appeal We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you or your representative. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information. You may give us your additional information to support your appeal by calling, faxing, or writing us at the numbers or address listed under Part D Appeals (for appeals about Part D drugs) in Section 8. You may also deliver additional information in person to the address listed under Part D Appeals (for appeals about Part D drugs) in Section 8. You also have the right to ask us for a copy of information regarding your appeal. You may call or write us at the phone number or address listed under Part D Appeals (for appeals about Part D drugs) in Section 8. How soon must we decide on your appeal?
We will give you our decision within seven calendar days of receiving the appeal request. We will give you the decision sooner if you have not received the drug yet and your health condition requires us to. If we do not give you our decision within seven calendar days, your request will automatically go to Appeal Level 2.
Appeal Level 2: Independent Review Entity (IRE) At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity. If you asked for Part D drugs or payment for Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the IRE. If you choose to appeal, you must send the appeal request to the IRE. The decision you receive from the Plan (Appeal Level 1) will tell you how to file this appeal, including who can file the appeal and how soon it must be filed. How soon must the IRE decide? The IRE has the same amount of time to make its decision as the Plan had at Appeal Level 1. If the IRE decides completely in your favor: The IRE will tell you in writing about its decision and the reasons for it.
Appeal Level 3: Administrative Law Judge (ALJ) If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part D drug you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record (by either receiving a copy of the file or accessing the file in person when feasible), and be represented by counsel. The request must be filed with an ALJ within 60 calendar days of the date you were notified of the decision made by the IRE (Appeal Level 2). The ALJ may give you more time if you have a good reason for missing the deadline. The decision you receive from the IRE will tell you how to file this appeal, including who can file it. The ALJ will not review your appeal if the dollar value of the requested Part D drug does not meet the minimum requirement specified in the IRE's decision. If the dollar value is less than the minimum requirement, you may not appeal any further. How soon will the Judge make a decision? The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as possible. If the Judge decides in your favor: See the section "Favorable Decisions by the ALJ, MAC, or a Federal Court Judge" below for information about what we must do if our decision of denying what you asked for is reversed by an ALJ. Appeal Level 4: Medicare Appeals Council (MAC) If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC). The request must be filed with the MAC within 60 calendar days of the date you were notified of the decision made by the ALJ (Appeal Level 3). The MAC may give you more time if you have a good reason for missing the deadline. The decision you receive from the ALJ will tell you how to file this appeal, including who can file it. How soon will the Council make a decision? The MAC will first decide whether to review your case (it does not review every case it receives). If the MAC reviews your case, it will make a decision as soon as possible. If it decides not to review your case, you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a written notice explaining any decision it makes. The notice will tell you how to request a review by a Federal Court Judge. If the Council decides in your favor: See the section "Favorable Decisions by the ALJ, MAC, or a Federal Court Judge" below for information about what we must do if our decision denying what you asked for is reversed by the MAC. You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and: |
