Evidence of Coverage:

Transcription

1 Jauary 1 December 31, 2012 Evidece of Coverage: Your Medicare Prescriptio Drug Coverage as a Member of CIGNA Medicare Rx Pla Two (PDP) Medicare Prescriptio Drug Pla This booklet gives you the details about your Medicare prescriptio drug coverage from Jauary 1 December 31, It explais how to get the prescriptio drugs you eed covered. This is a importat legal documet. Please keep it i a safe place. This pla, CIGNA Medicare Rx Pla Two (PDP), is offered by Coecticut Geeral Life Isurace Compay. (Whe this Evidece of Coverage says we, us, or our, it meas Coecticut Geeral Life Isurace Compay. Whe it says pla or our pla, it meas CIGNA Medicare Rx Pla Two (PDP).) Coecticut Geeral Life Isurace Compay is a Medicare-approved Part D sposor. This iformatio is available for free i other laguages. Please cotact our Customer Service umber at for additioal iformatio. (TTY users should call ). Hours are 8 am 8 pm, local time, 7 days a week. Customer Service also has free laguage iterpreter services available for o-eglish speakers Esta iformació está dispoible si cargo e otros idiomas. Para obteer iformació adicioal, comuíquese co el úmero de Servicio de ateció al cliete al (Los usuarios de TTY debe llamar al ). Nuestro horario es de 8 a. m. a 8 p. m., hora local, los 7 días de la semaa. El Servicio de ateció al cliete cueta co servicios de iterpretació gratuitos para aquellas persoas que o habla iglés. This iformatio is available for free i a differet format, Braille or Large Prit. Please call Customer Service at the umber listed above if you eed pla iformatio i aother format. Beefits, formulary, pharmacy etwork, premium, deductible, ad/or copaymets/ coisurace may chage o Jauary 1, /11 S5617_3435c_172 File & Use

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3 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) TABLE OF CONTENTS 2012 Evidece of Coverage Table of Cotets This list of chapters ad page umbers is just your startig poit. For more help i fidig iformatio you eed, go to the first page of a chapter. You will fid a detailed list of topics at the begiig of each chapter. CHAPTER 1. GETTING STARTED AS A MEMBER Tells what it meas to be i a Medicare prescriptio drug pla ad how to use this booklet. Tells about materials we will sed you, your pla premium, your pla membership card, ad keepig your membership record up to date. CHAPTER 2. IMPORTANT PHONE NUMBERS AND RESOURCES Tells you how to get i touch with our pla (CIGNA Medicare Rx Pla Two (PDP)) ad with other orgaizatios icludig Medicare, the State Health Isurace Assistace Program (SHIP), the Quality Improvemet Orgaizatio, Social Security, Medicaid (the state health isurace program for people with low icomes), programs that help people pay for their prescriptio drugs, ad the Railroad Retiremet Board. CHAPTER 3. USING THE PLAN S COVERAGE FOR YOUR PART D PRESCRIPTION DRUGS Explais rules you eed to follow whe you get your Part D drugs. Tells how to use the pla s List of Covered Drugs (Formulary) to fid out which drugs are covered. Tells which kids of drugs are ot covered. Explais several kids of restrictios that apply to coverage for certai drugs. Explais where to get your prescriptios filled. Tells about the pla s programs for drug safety ad maagig medicatios. CHAPTER 4. WHAT YOU PAY FOR YOUR PART D PRESCRIPTION DRUGS Tells about the three stages of drug coverage (Iitial Coverage Period, Coverage Gap Stage, Catastrophic Coverage Stage) ad how these stages affect what you pay for your drugs. Explais the five cost-sharig tiers for your Part D drugs ad tells what you must pay for a drug i each cost-sharig tier. Tells about the late erollmet pealty. CHAPTER 5. ASKING US TO PAY OUR SHARE OF THE COSTS FOR COVERED DRUGS Tells whe ad how to sed a bill to us whe you wat to ask us to pay you back for our share of the cost for your covered drugs. CHAPTER 6. YOUR RIGHTS AND RESPONSIBILITIES Explais the rights ad resposibilities you have as a member of our pla. Tells what you ca do if you thik your rights are ot beig respected. Page 1

4 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) TABLE OF CONTENTS CHAPTER 7. WHAT TO DO IF YOU HAVE A PROBLEM OR COMPLAINT (COVERAGE DECISIONS, APPEALS, COMPLAINTS) Tells you step-by-step what to do if you are havig problems or cocers as a member of our pla. Explais how to ask for coverage decisios ad make appeals if you are havig trouble gettig the prescriptio drugs you thik are covered by our pla. This icludes askig us to make exceptios to the rules ad/or extra restrictios o your coverage. Explais how to make complaits about quality of care, waitig times, customer service, ad other cocers. CHAPTER 8. ENDING YOUR MEMBERSHIP IN THE PLAN Tells whe ad how you ca ed your membership i the pla. Explais situatios i which our pla is required to ed your membership. CHAPTER 9. LEGAL NOTICES Icludes otices about goverig law ad about odiscrimiatio. CHAPTER 10. DEFINITIONS OF IMPORTANT WORDS Explais key terms used i this booklet. APPENDIX A. STATE HEALTH INSURANCE ASSISTANCE PROGRAM SHIP CHART APPENDIX B. QUALITY IMPROVEMENT ORGANIZATION QIO CHART APPENDIX C. MEDICAID AGENCIES APPENDIX D. STATE PHARMACY ASSISTANCE PROGRAMS SPAP CHART APPENDIX E. ADVANCE DIRECTIVES CHART Page 2

5 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) Chapter 1. Gettig started as a member CHAPTER 1 GETTING STARTED AS A MEMBER SECTION 1 INTRODUCTION Sectio 1.1 You are erolled i CIGNA Medicare Rx Pla Two (PDP), which is a Medicare Prescriptio Drug Pla Sectio 1.2 What is the Evidece of Coverage booklet about? Sectio 1.3 What does this Chapter tell you? Sectio 1.4 What if you are ew to CIGNA Medicare Rx Pla Two (PDP)? Sectio 1.5 Legal iformatio about the Evidece of Coverage SECTION 2 WHAT MAKES YOU ELIGIBLE TO BE A PLAN MEMBER? Sectio 2.1 Your eligibility requiremets Sectio 2.2 What are Medicare Part A ad Medicare Part B? Sectio 2.3 Here is the pla service area for CIGNA Medicare Rx Pla Two (PDP) SECTION 3 WHAT OTHER MATERIALS WILL YOU GET FROM US? Sectio 3.1 Your pla membership card Use it to get all covered prescriptio drugs Sectio 3.2 The Pharmacy Directory: Your guide to pharmacies i our etwork Sectio 3.3 The pla s List of Covered Drugs (Formulary) Sectio 3.4 The Explaatio of Beefits (the EOB ): Reports with a summary of paymets made for your Part D prescriptio drugs SECTION 4 YOUR MONTHLY PREMIUM FOR CIGNA MEDICARE RX PLAN TWO (PDP) Sectio 4.1 How much is your pla premium? Sectio 4.2 There are several ways you ca pay your pla premium Sectio 4.3 Ca we chage your mothly pla premium durig the year? SECTION 5 PLEASE KEEP YOUR PLAN MEMBERSHIP RECORD UP TO DATE Sectio 5.1 How to help make sure that we have accurate iformatio about you SECTION 6 WE PROTECT THE PRIVACY OF YOUR PERSONAL HEALTH INFORMATION Sectio 6.1 We make sure that your health iformatio is protected SECTION 7 HOW OTHER INSURANCE WORKS WITH OUR PLAN Sectio 7.1 Which pla pays first whe you have other isurace? Page 3

6 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER SECTION 1 Sectio 1.1 Itroductio You are erolled i CIGNA Medicare Rx Pla Two (PDP), which is a Medicare Prescriptio Drug Pla You are covered by Origial Medicare for your health care coverage, ad you have chose to get your Medicare prescriptio drug coverage through our pla, CIGNA Medicare Rx Pla Two (PDP). There are differet types of Medicare plas. CIGNA Medicare Rx Pla Two (PDP) is a Medicare prescriptio drug pla (PDP). Like all Medicare plas, this Medicare prescriptio drug pla is approved by Medicare ad ru by a private compay. Sectio 1.2 What is the Evidece of Coverage booklet about? This Evidece of Coverage booklet tells you how to get your Medicare prescriptio drug coverage through our pla. This booklet explais your rights ad resposibilities, what is covered, ad what you pay as a member of the pla. This pla, CIGNA Medicare Rx Pla Two (PDP), is offered by Coecticut Geeral Life Isurace Compay. (Whe this Evidece of Coverage says we, us, or our, it meas Coecticut Geeral Life Isurace Compay. Whe it says pla or our pla, it meas CIGNA Medicare Rx Pla Two (PDP).) The word coverage ad covered drugs refers to the prescriptio drug coverage available to you as a member of CIGNA Medicare Rx Pla Two (PDP). Sectio 1.3 What does this Chapter tell you? Look through Chapter 1 of this Evidece of Coverage to lear: What makes you eligible to be a pla member? What is your pla s service area? What materials will you get from us? What is your pla premium ad how ca you pay it? How do you keep the iformatio i your membership record up to date? Sectio 1.4 What if you are ew to CIGNA Medicare Rx Pla Two (PDP)? If you are a ew member, the it s importat for you to lear how the pla operates what the rules are ad what coverage is available to you. We ecourage you to set aside some time to look through this Evidece of Coverage booklet. If you are cofused or cocered or just have a questio, please cotact our pla s Customer Service (cotact iformatio is o the back cover of this booklet). Sectio 1.5 Legal iformatio about the Evidece of Coverage It s part of our cotract with you This Evidece of Coverage is part of our cotract with you about how CIGNA Medicare Rx Pla Two (PDP) covers your care. Other parts of this cotract iclude your erollmet form, the List of Covered Drugs (Formulary), ad ay otices you receive from us about chages to Page 4

7 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER your coverage or coditios that affect your coverage. These otices are sometimes called riders or amedmets. The cotract is i effect for moths i which you are erolled i CIGNA Medicare Rx Pla Two (PDP) betwee Jauary 1, 2012 ad December 31, Medicare must approve our pla each year Medicare (the Ceters for Medicare & Medicaid Services) must approve CIGNA Medicare Rx Pla Two (PDP) each year. You ca cotiue to get Medicare coverage as a member of our pla oly as log as we choose to cotiue to offer the pla for the year i questio ad the Ceters for Medicare & Medicaid Services reews its approval of the pla. SECTION 2 What makes you eligible to be a pla member? Sectio 2.1 Your eligibility requiremets You are eligible for membership i our pla as log as: You live i our geographic service area (sectio 2.3 below describes our service area) ad you are etitled to Medicare Part A or you are erolled i Medicare Part B (or you have both Part A ad Part B) Sectio 2.2 What are Medicare Part A ad Medicare Part B? Whe you origially siged up for Medicare, you received iformatio about how to get Medicare Part A ad Medicare Part B. Remember: Medicare Part A geerally covers services furished by istitutioal providers such as hospitals, skilled ursig facilities, or home health agecies. Medicare Part B is for most other medical services (such as physicia s services ad other outpatiet services) ad certai items (such as durable medical equipmet ad supplies). Sectio 2.3 Here is the pla service area for CIGNA Medicare Rx Pla Two (PDP) Although Medicare is a Federal program, CIGNA Medicare Rx Pla Two (PDP) is available oly to idividuals who live i our pla service area. To remai a member of our pla, you must keep livig i this service area. The service area is described below: Our service area icludes these states: Alabama, Arizoa, Arkasas, Coecticut, Florida, Illiois, Idiaa, Iowa, Ketucky, Massachusetts, Michiga, Miesota, Missouri, Motaa, Nebraska, North Carolia, North Dakota, Ohio, Pesylvaia, Rhode Islad, South Carolia, South Dakota, Teessee, Texas, Vermot, Virgiia, West Virgiia ad Wyomig. We offer coverage i several states. However, there may be cost or other differeces betwee the plas we offer i each state. If you move out of the state where you live ito a state that is still withi our service area, you must call Customer Service i order to update your iformatio. If you move ito a state outside of our service area, you ca ot remai a member of our pla. Please call Customer Service to fid out if we have a pla i your ew state. Page 5

8 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER If you pla to move out of the service area, please cotact Customer Service. Whe you move, you will have a Special Erollmet Period that will allow you to eroll i a Medicare health or drug pla that is available i your ew locatio. SECTION 3 What other materials will you get from us? Sectio 3.1 Your pla membership card Use it to get all covered prescriptio drugs While you are a member of our pla, you must use your membership card for our pla for prescriptio drugs you get at etwork pharmacies. Here s a sample membership card to show you what yours will look like: You may eed to use your red, white, ad blue Medicare card to get covered medical care ad services uder Origial Medicare. Sectio 3.2 The Pharmacy Directory: Your guide to pharmacies i our etwork Every year that you are a member of our pla, we will sed you either a ew Pharmacy Directory or a update to your Pharmacy Directory. This directory lists our etwork pharmacies. What are etwork pharmacies? Our Pharmacy Directory gives you a complete list of our etwork pharmacies that meas all of the pharmacies that have agreed to fill covered prescriptios for our pla members. Why do you eed to kow about etwork pharmacies? You ca use the Pharmacy Directory to fid the etwork pharmacy you wat to use. This is importat because, with few exceptios, you must get your prescriptios filled at oe of our etwork pharmacies if you wat our pla to cover (help you pay for) them. If you do t have the Pharmacy Directory, you ca get a copy from Customer Service (phoe umbers are o the back cover of this booklet). At ay time, you ca call Customer Service to get up-to-date iformatio about chages i the pharmacy etwork. You ca also fid this iformatio o our website at Please carry your card with you at all times ad remember to show your card whe you get covered drugs. If your pla membership card is damaged, lost, or stole, call Customer Service right away ad we will sed you a ew card. Sectio 3.3 The pla s List of Covered Drugs (Formulary) The pla has a List of Covered Drugs (Formulary). We call it the Drug List for short. It tells which Part D prescriptio Page 6

9 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER drugs are covered by CIGNA Medicare Rx Pla Two (PDP). The drugs o this list are selected by the pla with the help of a team of doctors ad pharmacists. The list must meet requiremets set by Medicare. Medicare has approved the CIGNA Medicare Rx Pla Two (PDP) Drug List. The Drug List also tells you if there are ay rules that restrict coverage for your drugs. We will sed you a copy of the Drug List. The Drug List we sed to you icludes iformatio for the covered drugs that are most commoly used by our members. However, we cover additioal drugs that are ot icluded i the prited Drug List. If oe of your drugs is ot listed i the Drug List, you should visit our website or cotact Customer Service to fid out if we cover it. To get the most complete ad curret iformatio about which drugs are covered, you ca visit the pla s website ( or call Customer Service (phoe umbers are o the back cover of this booklet). Sectio 3.4 The Explaatio of Beefits (the EOB ): Reports with a summary of paymets made for your Part D prescriptio drugs Whe you use your Part D prescriptio drug beefits, we will sed you a summary report to help you uderstad ad keep track of paymets for your Part D prescriptio drugs. This summary report is called the Explaatio of Beefits (or the EOB ). The Explaatio of Beefits tells you the total amout you have spet o your Part D prescriptio drugs ad the total amout we have paid for each of your Part D prescriptio drugs durig the moth. Chapter 4 (What you pay for your Part D prescriptio drugs) gives more iformatio about the Explaatio of Beefits ad how it ca help you keep track of your drug coverage. A Explaatio of Beefits summary is also available upo request. To get a copy, please cotact Customer Service. SECTION 4 Your mothly premium for CIGNA Medicare Rx Pla Two (PDP) Sectio 4.1 How much is your pla premium? As a member of our pla, you pay a mothly pla premium. The table below shows the mothly pla premium amout for each regio we serve. I additio, you must cotiue to pay your Medicare Part B premium (uless your Part B premium is paid for you by Medicaid or aother third party). State(s) 2012 Pla Two Premiums Premium Alabama, Teessee $63.80 Arizoa $69.80 Arkasas $63.20 Coecticut, Massachusetts, $67.80 Rhode Islad, Vermot Florida $69.10 Illiois $73.00 Idiaa, Ketucky $67.40 Iowa, Miesota, Motaa, $69.40 Nebraska, North Dakota, South Dakota, Wyomig Michiga $61.00 Missouri $69.20 Page 7

10 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER North Carolia $66.60 Ohio $62.40 Pesylvaia, West Virgiia $65.40 South Carolia $61.60 Texas $74.20 Virgiia $62.30 I some situatios, your pla premium could be less There are programs to help people with limited resources pay for their drugs. These iclude Extra Help ad State Pharmaceutical Assistace Programs. Chapter 2, Sectio 7 tells more about these programs. If you qualify, erollig i the program might lower your mothly pla premium. If you are already erolled ad gettig help from oe of these programs, the iformatio about premiums i this Evidece of Coverage may ot apply to you. We have icluded a separate isert, called the Evidece of Coverage Rider for People Who Get Extra Help Payig for Prescriptio Drugs (LIS Rider), which tells you about your drug coverage. If you do t have this isert, please call Customer Service ad ask for the Evidece of Coverage Rider for People Who Get Extra Help Payig for Prescriptio Drugs (LIS Rider). Phoe umbers for Customer Service are o the back cover of this booklet. I some situatios, your pla premium could be more I some situatios, your pla premium could be more tha the amout listed above i Sectio 4.1. These situatios are described below. Most people pay a stadard mothly Part D premium. However, some people pay a extra amout because of their yearly icome. If your icome is $85,000 or above for a idividual (or married idividuals filig separately) or $170,000 or above for married couples, you must pay a extra amout for your Medicare Part D coverage. If you have to pay a extra amout, the Social Security Admiistratio, ot your Medicare pla, will sed you a letter tellig you what that extra amout will be. For more iformatio about Part D premiums based o icome, go to Chapter 4, Sectio 10 of this booklet. You ca also visit o the web or call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or you may call the Social Security Admiistratio at TTY users should call Some members are required to pay a late erollmet pealty because they did ot joi a Medicare drug pla whe they first became eligible or because they had a cotiuous period of 63 days or more whe they did t have creditable prescriptio drug coverage. ( Creditable meas the drug coverage is expected to pay, o average, at least as much as Medicare s stadard prescriptio drug coverage.) For these members, the late erollmet pealty is added to the pla s mothly premium. Their premium amout will be the mothly pla premium plus the amout of their late erollmet pealty. If you are required to pay the late erollmet pealty, the amout of your pealty depeds o how log Page 8

11 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER you waited before you erolled i drug coverage or how may moths you were without drug coverage after you became eligible. Chapter 4, Sectio 9 explais the late erollmet pealty. If you have a late erollmet pealty ad do ot pay it, you could be diserolled from the pla. May members are required to pay other Medicare premiums Some pla members will be payig a premium for Medicare Part A ad most pla members will be payig a premium for Medicare Part B, i additio to payig the mothly Part D pla premium. Your copy of Medicare & You 2012 gives iformatio about these premiums i the sectio called 2012 Medicare Costs. This explais how the Part B premium differs for people with differet icomes. Everyoe with Medicare receives a copy of Medicare & You each year i the fall. Those ew to Medicare receive it withi a moth after first sigig up. You ca also dowload a copy of Medicare & You 2012 from the Medicare website ( Or, you ca order a prited copy by phoe at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users call Sectio 4.2 There are several ways you ca pay your pla premium There are three ways you ca pay your pla premium. Chages to your premium paymet optios ca be made by cotactig our customer service departmet (phoe umbers are o the back cover of this booklet.) If you decide to chage the way you pay your premium, it ca take up to three moths for your ew paymet method to take effect. While we are processig your request for a ew paymet method, you are resposible for makig sure that your pla premium is paid o time. Optio 1: You ca pay by check You may decide to pay your mothly pla premium directly to our Pla with a check or moey order. Pla premiums are due i our office by the 1 st day of the covered moth. Please make sure to make your check or moey order payable to CIGNA Medicare Rx Pla Two (PDP) ad mail your paymet to: CIGNA Medicare Rx Pla Two (PDP) P.O. Box Pittsburgh, PA Optio 2: You ca have the pla premium take directly out of your bak accout or charged directly to your credit or debit card Istead of payig by check, you ca have your mothly pla premium automatically withdraw from your bak accout or charged directly to your credit card or debit card. To make this electio, you must complete ad sig the appropriate form i your Welcome Kit or Erollmet Form ad retur it to CIGNA Medicare Rx Pla Two (PDP). You ca call to request the paperwork, but you will ot be able to make this electio by phoe. Page 9

12 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER Optio 3: You ca have the pla premium take out of your mothly Social Security check You ca have the pla premium take out of your mothly Social Security check. Cotact Customer Service for more iformatio o how to pay your mothly pla premium this way. We will be happy to help you set this up. What to do if you are havig trouble payig your pla premium Your pla premium is due i our office by the first day of the covered moth. If we have ot received your premium by the first day of the covered moth, we will sed you a otice tellig you that your pla membership will ed if we do ot receive your premium paymet withi 2 moths from the premium due date. If you are havig trouble payig your premium o time, please cotact Customer Service to see if we ca direct you to programs that will help with your pla premium. If we ed your membership with the pla because you did ot pay your premiums, ad you do t curretly have prescriptio drug coverage the you will ot be able to receive Part D coverage util the aual electio period. At that time, you may either joi a stad-aloe prescriptio drug pla or a health pla that also provides drug coverage. (If you go without creditable drug coverage for more tha 63 days, you may have to pay a premium pealty whe you sig up for a Part D pla.) If we ed your membership because you did ot pay your premiums, you will still have coverage uder Origial Medicare. At the time we ed your membership, you may still owe us for premiums you have ot paid. We have the right to pursue collectio of these premiums. I the future, if you wat to eroll agai i our pla (or aother pla that we offer), you will eed to pay the late premiums before you ca eroll. If you thik we have wrogfully eded your membership, you have a right to appeal our decisio. For iformatio about how to appeal the termiatio of coverage, call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sectio 4.3 Ca we chage your mothly pla premium durig the year? No. We are ot allowed to chage the amout we charge for the pla s mothly pla premium durig the year. If the mothly pla premium chages for ext year we will tell you i September ad the chage will take effect o Jauary 1. However, i some cases the part of the premium that you have to pay ca chage durig the year. This happes if you become eligible for the Extra Help program or if you lose your eligibility for the Extra Help program durig the year. If a member qualifies for Extra Help with their prescriptio drug costs, the Extra Help program will pay part of the member s mothly pla premium. So a member who becomes eligible for Extra Help durig the year would begi to pay less toward their mothly premium. Ad a member who loses their eligibility durig the year will eed to start payig their full mothly premium. You ca fid out more about the Extra Help program i Chapter 2, Sectio 7. Page 10

13 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER SECTION 5 Please keep your pla membership record up to date Sectio 5.1 How to help make sure that we have accurate iformatio about you Your membership record has iformatio from your erollmet form, icludig your address ad telephoe umber. It shows your specific pla coverage. The pharmacists i the pla s etwork eed to have correct iformatio about you. These etwork providers use your membership record to kow what drugs are covered for you. Because of this, it is very importat that you help us keep your iformatio up to date. Let us kow about these chages: Chages to your ame, your address, or your phoe umber Chages i ay other medical or drug isurace coverage you have (such as from your employer, your spouse s employer, workers compesatio, or Medicaid) If you have ay liability claims, such as claims from a automobile accidet If you have bee admitted to a ursig home If your desigated resposible party (such as a caregiver) chages If ay of this iformatio chages, please let us kow by callig Customer Service (phoe umbers are o the back cover of this booklet). Read over the iformatio we sed you about ay other isurace coverage you have That s because we must coordiate ay other coverage you have with your beefits uder our pla. (For more iformatio about how our coverage works whe you have other isurace, see Sectio 7 i this chapter.) Oce each year, we will sed you a letter that lists ay other medical or drug isurace coverage that we kow about. Please read over this iformatio carefully. If it is correct, you do t eed to do aythig. If the iformatio is icorrect, or if you have other coverage that is ot listed, please call Customer Service (phoe umbers are o the back cover of this booklet). SECTION 6 We protect the privacy of your persoal health iformatio Sectio 6.1 We make sure that your health iformatio is protected Federal ad state laws protect the privacy of your medical records ad persoal health iformatio. We protect your persoal health iformatio as required by these laws. For more iformatio about how we protect your persoal health iformatio, please go to Chapter 6, Sectio 1.4 of this booklet. SECTION 7 How other isurace works with our pla Sectio 7.1 Which pla pays first whe you have other isurace? Whe you have other isurace (like employer group health coverage), there are rules set by Medicare that decide whether our pla or your other isurace pays first. Page 11

14 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 1 GETTING STARTED AS A MEMBER The isurace that pays first is called the primary payer ad pays up to the limits of its coverage. The oe that pays secod, called the secodary payer, oly pays if there are costs left ucovered by the primary coverage. The secodary payer may ot pay all of the ucovered costs. These rules apply for employer or uio group health pla coverage: If you have retiree coverage, Medicare pays first. If your group health pla coverage is based o your or a family member s curret employmet, who pays first depeds o your age, the size of the employer, ad whether you have Medicare based o age, disability, or Ed-stage Real Disease (ESRD): If you re uder 65 ad disabled ad you or your family member is still workig, your pla pays first if the employer has 100 or more employees or at least oe employer i a multiple employer pla has more tha 100 employees. If you re over 65 ad you or your spouse is still workig, the pla pays first if the employer has 20 or more employees or at least oe employer i a multiple employer pla has more tha 20 employees. Liability (icludig automobile isurace) Black lug beefits Workers compesatio Medicaid ad TRICARE ever pay first for Medicare-covered services. They oly pay after Medicare, employer group health plas, ad/ or Medigap have paid. If you have other isurace, tell your doctor, hospital, ad pharmacy. If you have questios about who pays first, or you eed to update your other isurace iformatio, call Customer Service (phoe umbers are o the back cover of this booklet.) You may eed to give your pla member ID umber to your other isurers (oce you have cofirmed their idetity) so your bills are paid correctly ad o time. If you have Medicare because of ESRD, your group health pla will pay first for the first 30 moths after you become eligible for Medicare. These types of coverage usually pay first for services related to each type: No-fault isurace (icludig automobile isurace) Page 12

15 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES Chapter 2. Importat phoe umbers ad resources SECTION 1 SECTION 2 SECTION 3 SECTION 4 CIGNA MEDICARE RX PLAN TWO (PDP) CONTACTS (how to cotact us, icludig how to reach Customer Service at the pla) MEDICARE (how to get help ad iformatio directly from the Federal Medicare program) STATE HEALTH INSURANCE ASSISTANCE PROGRAM (free help, iformatio, ad aswers to your questios about Medicare) QUALITY IMPROVEMENT ORGANIZATION (paid by Medicare to check o the quality of care for people with Medicare) SECTION 5 SOCIAL SECURITY SECTION 6 SECTION 7 MEDICAID (a joit Federal ad state program that helps with medical costs for some people with limited icome ad resources) INFORMATION ABOUT PROGRAMS TO HELP PEOPLE PAY FOR THEIR PRESCRIPTION DRUGS SECTION 8 HOW TO CONTACT THE RAILROAD RETIREMENT BOARD SECTION 9 DO YOU HAVE GROUP INSURANCE OR OTHER HEALTH INSURANCE FROM AN EMPLOYER? Page 13

16 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES SECTION 1 CIGNA Medicare Rx Pla Two (PDP) cotacts (how to cotact us, icludig how to reach Customer Service at the pla) How to cotact our pla s Customer Service For assistace with claims, billig or member card questios, please call or write to CIGNA Medicare Rx Pla Two (PDP) Customer Service. We will be happy to help you. Customer Service CALL Calls to this umber are free. 8:00 am 8:00 pm, local time, 7 days a week. Customer Service also has free laguage iterpreter services available for o-eglish speakers. TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. 8:00 am 8:00 pm, local time, 7 days a week. FAX How to cotact us whe you are askig for a coverage decisio about your Part D prescriptio drugs A coverage decisio is a decisio we make about your beefits ad coverage or about the amout we will pay for your Part D prescriptio drugs. For more iformatio o askig for coverage decisios about your Part D prescriptio drugs, see Chapter 7 (What to do if you have a problem or complait (coverage decisios, appeals, complaits)). You may call us if you have questios about our coverage decisio process. Coverage Decisios for Part D Prescriptio Drugs CALL Calls to this umber are free. Hours are Moday-Friday 8 am to 8 pm MST ad Saturday 7 am to 3 pm MST. TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. Hours are 8 am 8 pm, local time, 7 days a week. WRITE WEBSITE CIGNA Medicare Rx Pla Two (PDP) PO Box Westo, FL FAX WRITE CIGNA Pharmacy Services PO Box Phoeix, AZ WEBSITE Page 14

17 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES How to cotact us whe you are makig a appeal about your Part D prescriptio drugs A appeal is a formal way of askig us to review ad chage a coverage decisio we have made. For more iformatio o makig a appeal about your Part D prescriptio drugs, see Chapter 7 (What to do if you have a problem or complait (coverage decisios, appeals, complaits)). Appeals for Part D Prescriptio Drugs CALL Calls to this umber are free. 8 a.m. 8 p.m. local time, 7 days a week TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. 8 a.m. 8 p.m. local time, 7 days a week FAX WRITE CIGNA Pharmacy Services Attetio: Medicare Rx (PDP) Appeals PO Box Phoeix, AZ How to cotact us whe you are makig a complait about your Part D prescriptio drugs You ca make a complait about us or oe of our etwork pharmacies, icludig a complait about the quality of your care. This type of complait does ot ivolve coverage or paymet disputes. (If your problem is about the pla s coverage or paymet, you should look at the sectio above about makig a appeal.) For more iformatio o makig a complait about your Part D prescriptio drugs, see Chapter 7 (What to do if you have a problem or complait (coverage decisios, appeals, complaits)). Complaits about Part D prescriptio drugs CALL Calls to this umber are free. 8:00 am 8:00 pm, local time, 7 days a week. TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. 8:00 am 8:00 pm, local time, 7 days a week. FAX WEBSITE WRITE CIGNA Medicare Rx Pla Two (PDP) PO Box Westo, FL Page 15

18 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES Where to sed a request askig us to pay for our share of the cost of a drug you have received The coverage determiatio process icludes determiig requests that asks us to pay for our share of the costs of a drug that you have received. For more iformatio o situatios i which you may eed to ask the pla for reimbursemet or to pay a bill you have received from a provider, see Chapter 5 (Askig us to pay our share of the costs for covered drugs). Paymet Requests CALL ; Moday through Friday from 8:00 am 11:00 pm, EST, Saturday from 9:00 am to 6:00 pm EST Calls to this umber are free. TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. Moday through Friday from 8:00 am 11:00 pm, EST, Saturday from 9:00 am to 6:00 pm EST. FAX WRITE WEBSITE CIGNA Medicare Rx Pla Two (PDP) Pharmacy Service Ceter P.O. Box 5950 Scrato, PA SECTION 2 Medicare (how to get help ad iformatio directly from the Federal Medicare program) Medicare is the Federal health isurace program for people 65 years of age or older, some people uder age 65 with disabilities, ad people with Ed-Stage Real Disease (permaet kidey failure requirig dialysis or a kidey trasplat). The Federal agecy i charge of Medicare is the Ceters for Medicare & Medicaid Services (sometimes called CMS ). This agecy cotracts with Medicare Prescriptio Drug Plas, icludig us. Medicare CALL MEDICARE, or Calls to this umber are free. 24 hours a day, 7 days a week. TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. WEBSITE This is the official govermet website for Medicare. It gives you up-to-date iformatio about Medicare ad curret Medicare issues. It also has iformatio about hospitals, ursig homes, physicias, home health agecies, ad dialysis facilities. It icludes booklets you ca prit directly from your computer. You ca also fid Medicare cotacts i your state by selectig Help ad Support ad the clickig o Useful Phoe Numbers ad Websites. Page 16

19 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES Medicare WEBSITE (cotiued from previous page) The Medicare website also has detailed iformatio about your Medicare eligibility ad erollmet optios with the followig tools: Medicare Eligibility Tool: Provides Medicare eligibility status iformatio. Select Fid Out if You re Eligible. Medicare Pla Fider: Provides persoalized iformatio about available Medicare prescriptio drug plas, Medicare health plas, ad Medigap (Medicare Supplemet Isurace) policies i your area. Select Health & Drug Plas ad the Compare Drug ad Health Plas or Compare Medigap Policies. These tools provide a estimate of what your out-of-pocket costs might be i differet Medicare plas. If you do t have a computer, your local library or seior ceter may be able to help you visit this website usig its computer. Or, you ca call Medicare at the umber above ad tell them what iformatio you are lookig for. They will fid the iformatio o the website, prit it out, ad sed it to you. SECTION 3 State Health Isurace Assistace Program (free help, iformatio, ad aswers to your questios about Medicare) The State Health Isurace Assistace Program (SHIP) is a govermet program with traied couselors i every state. See Appedix A of this booklet for a list of the State Health Isurace Assistace Programs. SHIP is idepedet (ot coected with ay isurace compay or health pla). It is a state program that gets moey from the Federal govermet to give free local health isurace couselig to people with Medicare. SHIP couselors ca help you with your Medicare questios or problems. They ca help you uderstad your Medicare rights, help you make complaits about your medical care or treatmet, ad help you straighte out problems with your Medicare bills. SHIP couselors ca also help you uderstad your Medicare pla choices ad aswer questios about switchig plas. SECTION 4 Quality Improvemet Orgaizatio (paid by Medicare to check o the quality of care for people with Medicare) There is a Quality Improvemet Orgaizatio for each state. See Appedix B of this booklet for a list of the Quality Improvemet Orgaizatios Quality Improvemet Orgaizatios have a group of doctors ad other health care professioals who are paid by the Federal govermet. This orgaizatio is paid by Medicare to check o ad help improve the quality of care for people with Medicare. Page 17

20 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES Quality Improvemet Orgaizatios are idepedet orgaizatios. It is ot coected with our pla. You should cotact the Quality Improvemet Orgaizatio if you have a complait about the quality of care you have received. For example, you ca cotact the Quality Improvemet Orgaizatio if you were give the wrog medicatio or if you were give medicatios that iteract i a egative way. SECTION 5 Social Security The Social Security Admiistratio is resposible for determiig eligibility ad hadlig erollmet for Medicare. U.S. citizes who are 65 or older, or who have a disability or Ed-Stage Real Disease ad meet certai coditios, are eligible for Medicare. If you are already gettig Social Security checks, erollmet ito Medicare is automatic. If you are ot gettig Social Security checks, you have to eroll i Medicare. Social Security hadles the erollmet process for Medicare. To apply for Medicare, you ca call Social Security or visit your local Social Security office. Social Security Admiistratio CALL Calls to this umber are free. Available 7:00 am to 7:00 pm, Moday through Friday. You ca use Social Security s automated telephoe services to get recorded iformatio ad coduct some busiess 24 hours a day. TTY WEBSITE This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are free. Available 7:00 am ET to 7:00 pm, Moday through Friday. SECTION 6 Medicaid (a joit Federal ad state program that helps with medical costs for some people with limited icome ad resources) Medicaid is a joit Federal ad state govermet program that helps with medical costs for certai people with limited icomes ad resources. Some people with Medicare are also eligible for Medicaid. Page 18

21 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES I additio, 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 icome ad resources save moey each year: Qualified Medicare Beeficiary (QMB): Helps pay Medicare Part A ad Part B premiums, ad other cost sharig (like deductibles, coisurace, ad copaymets). Specified Low-Icome Medicare Beeficiary (SLMB) ad Qualifyig Idividual (QI): Helps pay Part B premiums. Qualified Disabled & Workig Idividuals (QDWI): Helps pay Part A premiums. To fid out more about Medicaid ad its programs, cotact the Medicaid Agecy for your state listed i Appedix C of this booklet. SECTION 7 Iformatio about programs to help people pay for their prescriptio drugs Medicare s Extra Help Program Medicare provides Extra Help to pay prescriptio drug costs for people who have limited icome ad resources. Resources iclude your savigs ad stocks, but ot your home or car. If you qualify, you get help payig for ay Medicare drug pla s mothly premium ad prescriptio copaymets or coisurace. This Extra Help also couts toward your out-of-pocket costs. People with limited icome ad resources may qualify for Extra Help. Some people automatically qualify for Extra Help ad do t eed 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 prescriptio drug premiums ad costs. To see if you qualify for gettig Extra Help, call: MEDICARE ( ). TTY users should call , 24 hours a day, 7 days a week; The Social Security Office at , betwee 7 am to 7 pm, Moday through Friday. TTY users should call ; or Your State Medicaid Office. (See Sectio 6 of this chapter for cotact iformatio) If you believe you have qualified for Extra Help ad you believe that you are payig a icorrect cost-sharig amout whe you get your prescriptio at a pharmacy, our pla has established a process that allows you to either request assistace i obtaiig evidece of your proper co-paymet level, or, if you already have the evidece, to provide this evidece to us. CMS requires that pla sposors use the best available evidece to make chages to member records whe the pla has kowledge that a beeficiary s iformatio is ot correct. Cotact the Customer Service umber to get a list of the types of evidece that Pla sposors ca accept. Oce we receive the evidece it is validated, ad the correctios are updated. Page 19

22 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES Whe we receive the evidece showig your copaymet level, we will update our system so that you ca pay the correct copaymet whe you get your ext prescriptio at the pharmacy. If you overpay your copaymet, we will reimburse you. Either we will forward a check to you i the amout of your overpaymet or we will offset future copaymets. If the pharmacy has t collected a copaymet from you ad is carryig your copaymet as a debt owed by you, we may make the paymet directly to the pharmacy. If a state paid o your behalf, we may make paymet directly to the state. Please cotact Customer Service if you have questios. you pay ad the amout discouted by the maufacturer cout toward your out-of-pocket costs as if you had paid them ad moves you through the coverage gap. You also receive some coverage for geeric drugs. If you reach the coverage gap, the pla pays 14% of the price for geeric drugs ad you pay the remaiig 86% of the price. The coverage for geeric drugs works differetly tha the 50% discout for brad ame drugs. For geeric drugs, the amout paid by the pla (14%) does ot cout toward your out-ofpocket costs. Oly the amout you pay couts ad moves you through the coverage gap. Also, the dispesig fee is icluded as part of the cost of the drug. Medicare Coverage Gap Discout Program The Medicare Coverage Gap Discout Program is available atiowide. Because CIGNA Medicare Rx Pla Two (PDP) offers additioal gap coverage durig the coverage gap stage, your out-of-pocket costs will sometimes be lower tha the costs described here. Please go to Chapter 4, Sectio 6 for more iformatio about your coverage durig the coverage gap stage. The Medicare Coverage Gap Discout Program provides maufacturer discouts o brad ame drugs to Part D erollees who have reached the coverage gap ad are ot already receivig Extra Help. A 50% discout o the egotiated price (excludig the dispesig fee ad vaccie admiistratio fee, if ay) is available for those brad ame drugs from maufacturers that have agreed to pay the discout. If you reach the coverage gap, we will automatically apply the discout whe your pharmacy bills you for your prescriptio ad your Explaatio of Beefits (EOB) will show ay discout provided. Both the amout If you have ay questios about the availability of discouts for the drugs you are takig or about the Medicare Coverage Gap Discout Program i geeral, please cotact Customer Service (phoe umbers are o the back cover of this booklet). What if you have coverage from a State Pharmaceutical Assistace Program (SPAP)? If you are erolled i a State Pharmaceutical Assistace Program (SPAP), or ay other program that provides coverage for Part D drugs (other tha Extra Help), you still get the 50% discout o covered brad ame drugs. The 50% discout is applied to the price of the drug before ay SPAP or other coverage. What if you get Extra Help from Medicare to help pay your prescriptio drug costs? Ca you get the discouts? No. If you get Extra Help, you already get coverage for your prescriptio drug costs durig the coverage gap. Page 20

23 2012 Evidece of Coverage for CIGNA Medicare Rx Pla Two (PDP) CHAPTER 2 IMPORTANT PHONE NUMBERS AND RESOURCES What if you do t get a discout, ad you thik you should have? If you thik that you have reached the coverage gap ad did ot get a discout whe you paid for your brad ame drug, you should review your ext Explaatio of Beefits (EOB) otice. If the discout does t appear o your Explaatio of Beefits, you should cotact us to make sure that your prescriptio records are correct ad up-to-date. If we do t agree that you are owed a discout, you ca appeal. You ca get help filig a appeal from your State Health Isurace Assistace Program (SHIP) (telephoe umbers are i Sectio 3 of this Chapter) or by callig MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call State Pharmaceutical Assistace Programs May states have State Pharmaceutical Assistace Programs that help some people pay for prescriptio drugs based o fiacial eed, age, or medical coditio. Each state has differet rules to provide drug coverage to its members. These programs provide limited icome ad medically eedy seiors ad idividuals with disabilities fiacial help for prescriptio drugs. See Appedix D of this booklet for a list of State Pharmaceutical Assistace Programs. SECTION 8 How to cotact the Railroad Retiremet Board The Railroad Retiremet Board is a idepedet Federal agecy that admiisters comprehesive beefit programs for the atio s railroad workers ad their families. If you have questios regardig your beefits from the Railroad Retiremet Board, cotact the agecy. Railroad Retiremet Board CALL Calls to this umber are free. Available 9:00 am to 3:30 pm, Moday through Friday If you have a touch-toe telephoe, recorded iformatio ad automated services are available 24 hours a day, icludig weekeds ad holidays. TTY This umber requires special telephoe equipmet ad is oly for people who have difficulties with hearig or speakig. Calls to this umber are ot free. WEBSITE SECTION 9 Do you have group isurace or other health isurace from a employer? If you (or your spouse) get beefits from your (or your spouse s) employer or retiree group, call the employer/uio beefits admiistrator or Customer Service if you have ay questios. You ca ask about your (or your spouse s) employer or retiree health or drug beefits, premiums, or erollmet period. If you have other prescriptio drug coverage through your (or your spouse s) employer or retiree group, please cotact that group s beefits admiistrator. The beefits admiistrator ca help you determie how your curret prescriptio drug coverage will work with our pla. Page 21