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Explanation of Benefits (EOB) SECTION 6: Important things to know about your drug coverage and your rights.
This section shows details some your rights in the Medicare Part D program and will read as follows
Your "Evidence of Coverage" [has OR if EOB is for a member with LIS, insert "and LIS Rider" have] the details about your drug coverage and costs
The Evidence of Coverage is our plan’s benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage. [If EOB is for a member with LIS, insert: Your LIS Rider ("Evidence of Coverage Rider for People Who Get Extra Help Paying for their Prescriptions") is a short separate document that tells what you pay for your prescriptions.] We have sent you a copy of the Evidence of Coverage [if EOB is for a member with LIS, insert: and LIS Rider]. If you need another copy [if EOB is for a member with LIS, insert: of either of these], please call us (phone numbers are on the cover of this summary). Remember, to get your drug coverage under our plan you must use pharmacies in our network, except in certain circumstances. Also, quantity limitations and restrictions may apply.
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What if you have problems related to coverage or payments for your drugs?
Your Evidence of Coverage has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for:
- [MA-PD insert: Chapter 7.] [PDP insert: Chapter 5.] Asking the plan to pay its share of a bill you have received for covered services or drugs.
- [MA-PD insert: Chapter 9.] [PDP insert: Chapter 7.] What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Here are things to keep in mind:
- When we decide whether a drug is covered and how much you pay, it’s called a "coverage decision." If you disagree with our coverage decision, you can appeal our decision (see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the Evidence of Coverage).
- Medicare has set the rules for how coverage decision and appeal are handled. These are legal procedures and the deadlines are important. The process can be done if your doctor tells us that your health requires a quick decision.
Q1Medicare Note: see: appeals level chart overview.
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Please ask for help if you need it. Here’s how:
- You can call us at [insert plan name] Member Services (phone numbers are on the cover of this monthly summary).
- You can call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.
- You can call your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your Evidence of Coverage.
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Did you know there are programs to help people pay for their drugs?
- "Extra Help" from Medicare. You may be able to get Extra Help to pay for your prescription drug premiums and costs. This program is also called the "low-income subsidy" or LIS. People whose yearly income and resources are below certain limits can qualify for this help. To see if you qualify for getting Extra Help, see Section [insert appropriate section number] of your Medicare & You [insert year] handbook or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. You can also call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778. You can also call your State Medicaid Office.
- Help from your state’s pharmaceutical assistance program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your Evidence of Coverage.
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