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Introduction to the Facilitated Enrollment Notice: Partial Subsidy Version What’s the purpose of this notice? This notice informs people with Medicare that because they qualify for Extra Help, Medicare will enroll them in a Medicare Prescription Drug Plan if they don’t enroll themselves or decline coverage. There are two versions of the notice: one for people who qualify for the full low-income subsidy and one for people who qualify for the partial low-income subsidy. People who qualify for the full low-income subsidy will get Extra Help to pay their full premiums and deductibles in certain plans and will have minimal cost sharing. People who qualify for the partial low- income subsidy will get Extra Help and pay reduced premiums, deductibles, and cost sharing. Each notice includes two pages. The first page is a letter printed on green paper that includes a list of plans for each region that have premiums at or below the regional low-income premium subsidy amount on the back. The second page of the notice includes questions and answers about Medicare prescription drug coverage on the front and back. Who gets this notice? Medicare mails the notice to people who get Supplemental Security Income (SSI) benefits, people who belong to Medicare Savings Programs (MSPs), or people who apply and qualify for Extra Help, and who have not yet joined a Medicare drug plan. This mailing is limited to those who currently get Medicare benefits through Original Medicare. We also exclude people enrolled in certain qualifying employer or union plans. How often does Medicare mail the notice? This notice is mailed on a daily basis. What should people do next? People with Medicare should consider their options carefully. If they don’t join a plan themselves or call 1-800-MEDICARE to decline joining a Medicare Prescription Drug Plan, Medicare will enroll them in the plan listed in the notice. People who want more information about Medicare prescription drug coverage can: Visit Medicare.gov and get personalized drug plan information. Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Call their State Health Insurance Assistance Programs (SHIP) for free, personalized health insurance counseling. See the “Medicare & You” handbook or call 1-800- MEDICARE for the phone number for their state. People should reference CMS Product No. 11191 if they call Medicare or their SHIP with questions.
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Introduction to the Facilitated Enrollment Notice: Partial Subsidy ...

Jan 03, 2017

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Page 1: Introduction to the Facilitated Enrollment Notice: Partial Subsidy ...

Introduction to the Facilitated Enrollment Notice: Partial Subsidy Version

What’s the purpose of this notice? This notice informs people with Medicare that because they qualify for Extra Help, Medicare will enroll them in a Medicare Prescription Drug Plan if they don’t enroll themselves or decline coverage. There are two versions of the notice: one for people who qualify for the full low-income subsidy and one for people who qualify for the partial low-income subsidy. People who qualify for the full low-income subsidy will get Extra Help to pay their full premiums and deductibles in certain plans and will have minimal cost sharing. People who qualify for the partial low- income subsidy will get Extra Help and pay reduced premiums, deductibles, and cost sharing. Each notice includes two pages. The first page is a letter printed on green paper that includes a list of plans for each region that have premiums at or below the regional low-income premium subsidy amount on the back. The second page of the notice includes questions and answers about Medicare prescription drug coverage on the front and back. Who gets this notice? Medicare mails the notice to people who get Supplemental Security Income (SSI) benefits, people who belong to Medicare Savings Programs (MSPs), or people who apply and qualify for Extra Help, and who have not yet joined a Medicare drug plan. This mailing is limited to those who currently get Medicare benefits through Original Medicare. We also exclude people enrolled in certain qualifying employer or union plans. How often does Medicare mail the notice? This notice is mailed on a daily basis. What should people do next? People with Medicare should consider their options carefully. If they don’t join a plan themselves or call 1-800-MEDICARE to decline joining a Medicare Prescription Drug Plan, Medicare will enroll them in the plan listed in the notice. People who want more information about Medicare prescription drug coverage can: • Visit Medicare.gov and get personalized drug plan information. • Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. • Call their State Health Insurance Assistance Programs (SHIP) for free, personalized health

insurance counseling. See the “Medicare & You” handbook or call 1-800- MEDICARE for the phone number for their state.

People should reference CMS Product No. 11191 if they call Medicare or their SHIP with questions.

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CMS Product No. 11191 - GREEN December 2017

<BENEFICIARY FULL NAME> <file creation date> <ADDRESS> <CITY STATE ZIP> Please keep this notice for your records. You’re getting this notice because you qualify for Extra Help paying Medicare prescription drug coverage costs. You’ll get this drug coverage at very low cost to you. To get Medicare drug coverage and the Extra Help, you need to join a Medicare drug plan.

What to do next: You have 3 options Option 1: You can join a Medicare drug plan on your own. See the list of plans on the back of this notice. You can join any one of these plans and pay <subsidy % or $0> of the monthly premium because you qualify for Extra Help. Option 2: Medicare will enroll you in a Medicare drug plan. If you don’t join a Medicare drug plan, Medicare will enroll you in <Organization Name>’s <Plan Name> and your coverage starts <Enrollment Effective Date>. Here’s what you’ll pay with this plan in 2018: • <subsidy % or $0> of the monthly prescription drug plan premium • Up to $83 of the yearly prescription drug plan deductible • Up to 15% of the cost of each prescription covered by the plan This plan serves <States>. If this isn’t where you live, call <Plan Name > at <Plan Phone> to make sure it serves where you live now. Bring this green notice when you get a prescription filled, so the pharmacist knows you qualify for Extra Help. If you need drug coverage before <enrollment effective date>, your pharmacist can bill Medicare’s Limited Income Newly Eligible Transition (NET) Program. Also, if you paid for any prescriptions before you got this notice, and you were eligible for Medicare and Medicaid, you may be able to get back part of what you paid. Call Medicare’s Limited Income NET Program for more information at 1-800-783-1307. TTY users can call 711. Option 3: You can decline Medicare drug coverage (“opt out”). If you currently have other drug coverage, like coverage from an employer or union, joining a Medicare drug plan may not be right for you. You may want to keep your current coverage and decline enrollment from Medicare. If you don’t want a Medicare drug plan, call 1-800-MEDICARE (1-800-633-4227) or the plan shown above and tell them you want to opt out of Medicare drug coverage. TTY users can call 1-877-486-2048. Where to go for more information For more information about <Plan Name>, call <Plan phone>, or visit <Plan Web Site>. For

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244-1850

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CMS Product No. 11191 - GREEN December 2017

help understanding this notice, call 1-800-MEDICARE. You can also call your local Office on Aging or your State Health Insurance Program at <SHIP phone number> for free, personalized health insurance counseling.

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Important questions & answers about your new drug coverage

What’s 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? Consider your 3 options carefully. If you don’t join a plan on your own or call 1-800-MEDICARE (1-800-633-4227) to opt out of (decline) Medicare prescription drug coverage, Medicare will enroll you in a drug plan. TTY users can call 1-877-486-2048. For free help in another language, say “Agent” at any time to talk to a customer service representative.

You may pay a premium to your plan each month. If you get a bill and don’t want the plan, call the plan or 1-800-MEDICARE to decline the coverage. If you want to keep the plan Medicare enrolls you in, you don’t have to do anything.

Call your 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 prescriptions 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 green 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 now. If it doesn’t, call 1-800-MEDICARE to choose and join a plan that serves your area.

What if my new plan doesn’t cover a drug I already take? Your Medicare drug plan will cover 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.

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How do I join a different plan? As long as you qualify for Extra Help, you 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. Compare the plans and join one that works for you. You should find out which plans cover the prescriptions you 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 a higher monthly premium.

You can also call your State Health Insurance Assistance Program (SHIP) for free, personalized health insurance counseling. See the first page 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. 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.

If you drop this coverage and need prescription drugs later, Medicare won’t pay until you join a Medicare drug plan. As long as you qualify for Extra Help, you can change your mind and join a Medicare drug plan at any time. You may have to pay a penalty to join later if you don’t still qualify for Extra Help.

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Nondiscrimination Notice - The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve been discriminated against or treated unfairly for any of these reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil Rights by:

• Calling 1-800-368-1019. TTY users can call 1-800-537-7697.• Visiting hhs.gov/ocr/civilrights/complaints.• Writing: Office for Civil Rights, U.S. Department of Health and Human Services, 200

Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201

Notice of Availability of Auxiliary Aids & Services - We’re committed to making our programs, benefits, services, facilities, information, and technology accessible in accordance with Sections 504 and 508 of the Rehabilitation Act of 1973. We’ll take appropriate steps to make sure that people with disabilities, including people who are deaf, hard of hearing or blind, or who have low vision or other sensory limitations, have an equal opportunity to participate in our services, activities, programs, and other benefits. We provide various auxiliary aids and services to communicate with people with disabilities, including:

• Relay service — TTY users can call 1-877-486-2048.• Alternate formats — This notice is available in alternate formats, including large print, Braille, data

CD and audio CD. To request your notice in an alternate format, call1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Aviso sobre la discriminación - Los Centros de Servicios de Medicare y Medicaid (CMS) no excluye, niega beneficios o discrimina contra ninguna persona por motivos de raza, color, origen nacional, incapacidad, género o edad. Si cree que ha sido discriminado o tratado injustamente por cualquiera de estos motivos, puede presentar una queja ante el Departamento de Salud y Servicios Humanos, Oficina de Derechos Civiles:

• Llamando al 1-800-368-1019. Los usuarios de TTY pueden llamar al 1-800-537-7697.• Visitando hhs.gov/ocr/civilrights/complaints.• Escribiendo a la: Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos

200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

Ayuda y servicios auxiliares para personas con incapacidades - Medicare está dedicado a ofrecerles a todos sus beneficiarios los programas, beneficios, servicios, dependencias, información y su tecnología, en cumplimiento con las Secciones 504 y 508 de la Ley de Rehabilitación del 1973. Medicare tomará las medidas necesarias para asegurarse de que las personas incapacitadas, entre los que se incluyen los que tiene problemas auditivos, son sordos, ciegos, tienen problemas visuales u otro tipo de limitaciones, tengan las mismas oportunidades de participar y aprovechar los programas y beneficios disponibles. Medicare ofrece varios servicios y ayuda para facilitar la comunicación con las personas incapacitadas incluyendo:

• Servicios de retransmisión de mensajes — Los usuarios de TTY pueden llamar al 1-877-486-2048.• Formatos alternativos — Los productos de Medicare, incluyendo este documento, están disponible

en letra grande, versión digital, Braille y audio. Para ordenar su aviso en un formato alternativo,llame al 1-800-MEDICARE (1-800-633-4227). Los usuarios de TTY pueden llamar al 1-877-486-2048.

_____________________________________________________________________________________________ ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-MEDICARE (TTY: 1-877-486-2048).

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(Arabic) 800-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برق ةيبرعلا-MEDICARE :1-2048-486-877(رقم ھاتف الصم والبكم.(

հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-800-MEDICARE (TTY (հեռատիպ)՝ 1-877-486-2048) 繁體中文 (Chinese) 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-800-MEDICARE(TTY: 1 -877-486-2048) 。

-800-1: اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می باشد. با توجھ (Farsi) فارسیMEDICARE (TTY: 1-877-486-2048) .تماس بگیرید

Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-MEDICARE (ATS : 1-877-486-2048).

Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-MEDICARE (TTY: 1-877-486-2048).

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-MEDICARE (TTY: 1-877-486-2048).

Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-MEDICARE (TTY: 1-877-486-2048).

日本語 (Japanese) 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-800-MEDICARE(TTY:1-877-486-2048)まで、お電話にてご連絡ください。

한국어(Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-MEDICARE (TTY: 1-877-486-2048) 번으로 전화해 주십시오.

Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-MEDICARE (TTY: 1-877-486-2048).

Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-MEDICARE (TTY: 1-877-486-2048).

Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-MEDICARE (телетайп: 1-877-486-2048).

Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-MEDICARE (TTY: 1-877-486-2048).

Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-MEDICARE (TTY: 1-877-486-2048).

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-MEDICARE (TTY: 1-877-486-2048).

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CMS Product No. 11191 December 2017

Medicare drug plans in Maine & New Hampshire

You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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.• What special drug coverage rules may affect your prescriptions (like prior

authorization, which means the plan won’t cover a specific drug unless the planapproves it first).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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.

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December 2017

Medicare drug plans in Connecticut, Massachusetts, Rhode Island & Vermont You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 the number listed on the other side of this page. 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.

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Medicare drug plans in New York You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-701-0501. 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.

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December 2017

Medicare drug plans in New Jersey You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-792-8820. 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.

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Medicare drug plans in Delaware, District of Columbia & Maryland You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 the number listed on the other side of this page. 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.

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Medicare drug plans in Pennsylvania & West Virginia You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-783-7067 (Pennsylvania) or 1-877-987-4463 (West Virginia). 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.

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Medicare drug plans in Virginia You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-552-3402. 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.

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Medicare drug plans in North Carolina You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-855-408-1212. 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.

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Medicare drug plans in South Carolina You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-868-9095. 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.

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Medicare drug plans in Georgia You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-866-552-4464. 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.

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December 2017

Medicare drug plans in Florida You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-963-5337. 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.

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December 2017

Medicare drug plans in Alabama & Tennessee You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-243-5463 (Alabama) or 1-877-801-0044 (Tennessee). 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.

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December 2017

Medicare drug plans in Michigan You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-803-7174. 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.

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December 2017

Medicare drug plans in Ohio You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-686-1578. 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.

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December 2017

Medicare drug plans in Indiana & Kentucky You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-452-4800 (Indiana) or 1-877-293-7447 (Kentucky). 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.

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Medicare drug plans in Wisconsin You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-242-1060. 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.

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December 2017

Medicare drug plans in Illinois You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-548-9034. 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.

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December 2017

Medicare drug plans in Missouri You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-390-3330. 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.

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Medicare drug plans in Arkansas You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-224-6330. 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.

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December 2017

Medicare drug plans in Mississippi You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-844-822-4622. 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.

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December 2017

Medicare drug plans in Louisiana You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-259-5300. 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.

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Medicare drug plans in Texas You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-252-9240. 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.

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December 2017

Medicare drug plans in Oklahoma You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-763-2828. 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.

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December 2017

Medicare drug plans in Kansas You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-860-5260. 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.

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Medicare drug plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota & Wyoming You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 the number listed on the other side of this page. 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.

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December 2017

Medicare drug plans in New Mexico You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-432-2080. 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.

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December 2017

Medicare drug plans in Colorado You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-888-696-7213. 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.

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December 2017

Medicare drug plans in Arizona You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-432-4040. 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.

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December 2017

Medicare drug plans in Nevada You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-307-4444. 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.

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December 2017

Medicare drug plans in Oregon & Washington You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-722-4134 (Oregon) or 1-800-562-6900 (Washington). 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.

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December 2017

Medicare drug plans in Idaho & Utah You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-247-4422 (Idaho) or 1-800-541-7735 (Utah). 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.

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December 2017

Medicare drug plans in California You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-434-0222. 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.

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December 2017

Medicare drug plans in Hawaii You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-888-875-9229. 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.

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Medicare drug plans in Alaska You can join any plan in the list below and pay the same premium and copayments listed on the front page of this notice. 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. • 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).

• What pharmacies you can use.

Get help comparing your drug plan options For help comparing plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can 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 1-800-478-6065. 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.