11154 WEB Nov 20111.pdf

CMS Product No. 11154 - YELLOW November 2011

<BENEFICIARY FULL NAME> HICN <1234>

<ADDRESS> <file creation date>

<CITY STATE ZIP>

Please keep this notice for your records. You’re getting this notice because you automatically qualify for Extra Help paying for Medicare prescription drug coverage.

You're Being Enrolled in a Medicare Drug Plan You qualify for Extra Help, so Medicare is enrolling you in a Medicare Prescription Drug Plan to make sure you get help paying for your prescription drugs. You’ll be enrolled in <Prospective Org Name>’s <Prospective Plan Name> starting <prospective effective date>.

Here’s what you’ll pay with this plan in 2012:

• $0 for your monthly prescription drug plan premium

• $0 for your yearly prescription drug plan deductible

• <insert LIS copayment amount> copayment for each prescription covered by the plan

Your plan serves <states>. If this isn’t where you live, please call <Prospective Plan Name> at <Prospective Plan Phone> to make sure it serves where you live now.

What to Do Next Call <Prospective Plan Name> at <Prospective Plan Phone> for details about your new Medicare drug coverage, or visit <Prospective Plan Web site>. If you don’t like this plan, see the back of this notice for a list of other Medicare drug plans, and join one that works for you.

Bring this yellow notice with you when you get a prescription filled, so the pharmacist knows you qualify for Extra Help.

If you filled any covered prescriptions before <prospective effective date>, you may be able to get back part of what these prescriptions cost if you were eligible for Medicare and Medicaid but not enrolled in a Medicare drug plan. Call Medicare’s Limited Income Newly Eligible Transition (NET) Program at 1-800-783-1307 for more information. TTY users should call 1-877-801-0369.

Important: If you have retiree drug coverage through an employer or union plan, joining a Medicare drug plan may NOT be right for you. Please read the important attached information, “What if I have other prescription drug coverage?”

Get Help & More Information To get help with your choices, call your State Health Insurance Assistance Program (SHIP) at <SHIP phone number> for free health insurance counseling, or call 1-800-MEDICARE (1-800-633-4227) for help. TTY users should call 1-877-486-2048.

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard Baltimore, MD 21244-1850

Important Questions and Answers about Your New Drug Coverage

What is Medicare prescription drug coverage?

Medicare prescription drug coverage is insurance provided by the government. Medicare drug plans help you pay for both brand-name and generic drugs you need. Plans have a list of drugs they cover. The drug list of a particular plan may not include a specific drug you’re taking.

However, in most cases, a similar drug that’s safe and effective will be available. If not, your doctor can ask the plan to make an exception and cover the drug you’re currently taking.

Medicare drug plans serving your area must contract with pharmacies in your area. Check with the plan to make sure the contracting pharmacies are convenient to you. Some plans also let you get prescriptions through the mail.

What should I do now?

Call your Medicare drug plan to get information about your new drug coverage, and read the materials your plan mails to you. You should find out if the plan covers the drugs you take and includes the pharmacies you use.

You may need to go to the pharmacy before your plan membership card arrives in the mail. If you do, bring this yellow notice, or a letter from the plan that shows your confirmation number.

That way the pharmacy can bill your plan directly. You should also bring your Medicare card and photo identification.

Note: If you moved recently, please call the plan to be sure it serves where you live. If it doesn’t, please call 1-800-MEDICARE (1-800-633-4227) to choose and join a plan that serves that area. TTY users should call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative.

What if my new plan doesn’t cover a drug I already take?

Your Medicare drug plan will provide a one-time, temporary supply of your current drug.

During your first 90 days in a plan, Medicare requires Medicare drug plans to give you and your doctor time to find a drug on the plan’s drug list that would work as well as the drug you’re taking. Your doctor can also contact your plan to request an exception to cover your current drug. Call your plan for more information.

How do I join a different plan?

As long as you qualify for Extra Help, you can switch Medicare drug plans at any time. To join a different Medicare drug plan, call the new plan to find out how to join. Joining a different plan will automatically end your coverage in (disenroll you from) your current plan. You don’t need to call your current plan to disenroll. Your new plan coverage would start the next month.

How can I find out about other Medicare drug plans?

For information about other Medicare drug plans in your area, read the list of plans included with this notice. You can join any plan in this list and still pay $0 for your monthly premium.

Compare the plans and join one that works for you. You should find out which plans cover the drugs you already take and include the pharmacies you use. If you join a Medicare drug plan that isn’t on the list included with this notice, you may have to pay part of the monthly premium instead of $0.

You can also call your State Health Insurance Assistance Program (SHIP) for free personalized health insurance counseling. See the front of this notice for their phone number.

What if I have other prescription drug coverage?

If you have or are eligible for another type of prescription coverage, read all the materials you get from your insurer or plan provider to learn how joining a Medicare drug plan may affect any coverage you or your family already have. You may not need a Medicare drug plan. Examples of other types of prescription drug coverage include coverage from an employer or union, TRICARE, the Department of Veterans Affairs, or a Medicare Supplement Insurance (Medigap) policy.

Note: If you now get drug or other health care coverage through an employer or union plan, you or your dependents could lose that coverage completely if you join a Medicare drug plan, and you may not be able to get it back. Please call your health plan benefits administrator if you have any questions.

What if I don’t want Medicare prescription drug coverage?

If you don’t want to join the plan Medicare is enrolling you in, and you don’t want any other Medicare drug plan, call 1-800-MEDICARE (1-800-633-4227) as soon as possible and tell them you want to opt out of (decline) Medicare prescription drug coverage.

Keep in mind that you pay nothing to keep the coverage. If you drop this coverage and need prescription drugs later, Medicaid won’t pay for them, and Medicare won’t pay until you join a Medicare drug plan. As long as you continue to be eligible for Medicaid, you can change your mind and join a Medicare drug plan at any time, but you may have to pay a penalty to join later if you lose your Medicaid eligibility.

Para obtener información en español, llame GRATIS al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY deben llamar al 1-877-486-2048.

Medicare Drug Plans in Maine & New Hampshire for $0 Premium

You can join any plan in the list below and pay $0 premium in 2012. You’ll pay up to $2.60 for a generic drug and up to $6.50 for a brand-name drug covered by the plan.

Since you qualify for Extra Help, you can join or switch Medicare drug plans anytime.

Compare the plans and join one that works for you. You should ask if the plan covers the drugs you take, about what special drug coverage rules may affect your prescriptions (like prior authorization, which means the plan won’t cover a specific drug unless the plan approves it first), and what pharmacies you can use.

Get Help Comparing Your Drug Plan Options For help comparing plans, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative. You can also call your State Health Insurance Assistance Program for free personalized health insurance counseling at 1-877-353-3771 (Maine) or 1-866-634-9412 (New Hampshire).

If you join a Medicare drug plan that isn’t listed above, you may have to pay a higher monthly premium. Be sure to ask about the premium when you’re comparing plans.