2008 MODEL ANNUAL NOTICE OF CHANGE
Annual Enrollment Period: November 15th to December 31st each year
Annual Enrollment Period: November 15th to December 31st each year
During this Annual Enrollment Period, you have the opportunity to switch plans. Take the opportunity to compare the benefits, costs, and restrictions of the plans available in your area and choose the plan that is best for you. If you are satisfied with your current plan, you do not need to take any action.
[NOTE: This notice must also be sent to all new members who enroll in a plan between October 31st and November 31st.]
[NOTE: include a notice on the cover of this document indicating that it is available in alternative formats (e.g., Spanish, large print, or audio tapes ), including any language that is the primary language of more than 10 percent of the geographic area.]
Dear <member name/Member>:
[Note: The organization may modify this introductory paragraph to tailor to its needs, as long as the paragraph is kept brief.] [This is the time of year when we like to thank you for your membership and let you know of new plan changes for the upcoming year. Beginning January 1, 2008, there will be some changes to <plan name>.] [PDPs rolling members into new plan or consolidating plans insert: "We want to take this opportunity to let you know of our new plan name for the upcoming year."]
The following are described in this letter:
• How will my monthly premium change for <year>?
• How will my prescription drug coverage and cost-sharing change for <year>?
• What if my drug is no longer on the formulary or is in a more expensive cost-sharing tier in <year>?
• What do I need to know if I'm getting extra help from Medicare to pay for my prescription drugs?
• What happens if I want to leave my current Medicare Prescription Drug Plan?
• Where can I get more information?
How will my monthly premium change for <year>?
Starting January 1, <year>, the monthly premium that you pay to < [new] plan name> will [<increase/decrease> from $<xx.xx> to $<xx.xx>] [stay the same at $ <xx.xx>.]
This amount does not include any late enrollment penalty (higher premium) you may be responsible for paying. Individuals without drug coverage that is at least as good as Medicare's standard prescription drug coverage (called "creditable prescription drug coverage"), may have to pay a late enrollment penalty (higher premium) when they sign up for Medicare prescription drug coverage. The longer an individual waits to enroll in a Medicare drug plan, the higher the penalty may be.
How will my prescription drug coverage and cost-sharing change for <year>?
[We have enclosed a <year> Summary of Benefits and a new formulary that will be effective January 1, <year>. Medicare has reviewed and approved the benefits described in the Summary of Benefits and covered drugs listed in the formulary.] [Delete above sentence if sending a combined ANOC/EOC. The SB is not required if the plan is sending a combined ANOC/EOC.] [Delete the following sentence if sending a combined ANOC/EOC.] [We will send you [If you are sending earlier than January 31, 2008, insert: "by <date>" Otherwise insert: "by January 31, 2008"] an Evidence of Coverage which will explain in detail all of our plan rules and benefits that will be in effect as of January 1, <year>.] All changes begin January 1, <year>, and will be in effect through December 31, <year>, except for mid-year formulary changes, which generally are limited to formulary changes that decrease cost or increase safety. Rest assured that you will still be a member of <[new] plan name> for the coming year if you do nothing to change your Medicare coverage. [SNPs insert language as appropriate describing the enrollment effect if the Medicaid eligibility status changes during the year.]
[Plans that have changed one or more of the following must clearly describe or compare the changes from the current benefit year to the upcoming benefit year:
• Tier structure
• Types of drugs in each tier
• Cost sharing
• Addition or removal of utilization management tools (prior authorization, step therapy, quantity limits, and mandatory generics). This information may be clearer to people with Medicare in table format.]
[Plans not automatically continuing approved exception requests into a subsequent plan year for renewing enrollees must add the following language if those enrollees are not otherwise notified in writing that the exceptions will not continue into the subsequent plan year: "If you received approval for a formulary or tiering exception request during the 2007 plan year, coverage for the drug approved under the exception will end on December 31, 2007. You will need to submit a new formulary or tiering exception request to continue coverage for the drug for the 2008 plan year."]
What if my drug is no longer on the formulary or is in a more expensive cost-sharing tier in <year>?
<We have changed our formulary. / The formulary for <plan name> may be different than the one you are using.> We have added, removed, or placed more limitations on some of the drugs we cover. Please review the formulary to see if we still cover the drugs that you currently take. [If including a complete formulary, use the following language: "The enclosed formulary can also be found on our <formulary web site> or you can call <customer/member> service if you need any help locating a certain drug."] [If including an abridged formulary, use the following language: "To get a complete listing of all the drugs we cover, you can visit our <formulary web site> or call <customer/member> service. You can also call <customer/member> service if you need any information about a certain drug."]
[Insert the following language if you allow enrollees to request exceptions for the upcoming plan year before the new plan year begins: If a drug we currently cover for you is not on our new formulary, you will need to talk with your doctor about taking an alternative drug that is available on our new formulary. If you wish to continue coverage of your current drug, you or your doctor can request a formulary exception. [If a drug we currently cover for you is on our new formulary but has been moved to the higher non-preferred cost-sharing tier, you can talk with your doctor about taking an alternative drug that is available in a lower cost-sharing tier. If you wish to pay the lower preferred cost-sharing amount for the drug, you or your doctor can request a tiering exception.] If you or your doctor would like to request an exception, the request should be made by <insert date>. Please refer to the enclosed <plan name> formulary for instructions on how to file an exception. If the formulary exception request is approved, we will continue covering your current drug on January 1. [If the tiering exception request is approved, we will cover your current drug at the preferred cost-sharing amount on January 1.]]
[Insert the following language if your plan does not allow enrollees to request exceptions for the upcoming plan year before the new plan year begins: If a drug we currently cover for you is not on our new formulary, you will need to talk with your doctor about taking an alternative drug that is available on our new formulary. If you wish to continue coverage of your current drug, you or your doctor can request a formulary exception on or after January 1. Beginning January 1, you will get a temporary supply of the drug we currently cover for you that is not on our new formulary. You will need to talk to your doctor about switching to a covered drug, or request a formulary exception before your temporary supply runs out. [If a drug we currently cover for you is on our new formulary but has been moved to the higher non-preferred cost-sharing tier, you can talk with your doctor about taking an alternative drug that is available in a lower cost-sharing tier. If you wish to pay the lower preferred cost-sharing amount for the drug, you or your doctor can request a tiering exception on or after January 1.] Please refer to the enclosed <plan name> formulary for exception filing instructions. ]
What do I need to know if I'm getting extra help from Medicare to pay for my prescription drugs?
If you continue to qualify for the same amount of help next year, the table below tells you how your prescription costs will change.
| If you pay up to this much this year (2007) |
You will pay up to this much next year (2008) |
| $0 deductible | $0 deductible |
| $53 deductible | $56 deductible |
| $1 for generics and brands that are treated as generics $3.10 for brand name drugs |
$1.05 for generics and brands that are treated as generics $3.10 for brand name drugs |
| $2.15 for generics and brands that are treated as generics $5.35 for brand name drugs |
$2.25 for generics and brands that are treated as generics $5.60 for brand name drugs |
| No more than 15% co-insurance for all drugs | No more than 15% co-insurance for all drugs |
If you qualify for extra help, you pay $0 or a reduced monthly premium. If you continue to qualify for the same amount of extra help in 2008, the table below tells how much you will pay for a monthly premium. (This doesn't include any Medicare Part B premium you may have to pay.) If you don't know your level of extra help, call us.
| Your level of extra help | Monthly Premium for <plan name> |
| 100% | $<xx.xx> |
| 75% | $<xx.xx> |
| 50% | $<xx.xx> |
| 25% | $<xx.xx> |
You may get (or may have gotten) a letter from Medicare or Social Security about your 2008 eligibility for extra help. Read this important information carefully. If you don't know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Customer service representatives are available 24 hours a day, including weekends.
[If plan will lose certain LIS beneficiaries to re-assignment to a plan within the same PDP sponsoring organization, insert the following language: "Because the monthly premium for the plan you had in 2007 is increasing in 2008, Medicare has told us to move you to <insert 2008 plan name> where you won't have to pay any monthly premium in 2008. If you want to stay with <insert 2007 plan name>, the plan you have in 2007, please call us at <customer service number/hours>. If you choose to stay with <insert 2007 plan name>, you will be responsible for paying a monthly premium.]
[If plan will lose certain LIS beneficiaries to re-assignment to a different PDP sponsoring organization, insert the following language: "If you qualify for extra help, you will get a blue letter from Medicare by early November. This letter explains that Medicare will enroll you in a new Medicare drug plan to lower your monthly premium cost in 2008. If you want to stay with our plan instead, please call us at <customer/member service number/hours>. Staying in our plan will cost you more than moving to the new plan."]
[For enhanced plans that have LIS members: "As an enhanced benefit, our plan includes additional coverage of some prescription drugs not normally covered in a Medicare Prescription Drug Plan. If you get extra help from Medicare in paying for your prescription drugs, you won't get this extra help for these particular drugs. Please refer to the enclosed formulary to see which drugs are covered by the enhanced benefit.] [Delete the following sentence if sending a combined ANOC/EOC. The SB is not required if the plan is sending a combined ANOC/EOC.] [Your co-payment/coinsurance amounts for these drugs are listed in the enclosed Summary of Benefits."]
What happens if I want to leave my current Medicare Prescription Drug Plan?
[If the organization lists only one plan in the Summary of Benefits but offers multiple plans in the service area, the ANOC must notify people with Medicare that more plans are available and include specific information on how beneficiaries can get more information.]
Every year, from November 15 - December 31, during the Annual Election Period (AEP), anyone with Medicare may switch Medicare plans. Your change will take effect on January 1. Outside of this time period, you generally can't make any other changes during the year unless you meet special exceptions, such as if you move, if you have Medicaid coverage, or if you get extra help in paying for your drugs.
For more information about these times and the choices available to you, look at your "Medicare & You" handbook. This handbook is mailed to everyone with Medicare each fall. You may also visit www.medicare.gov on the web or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Where can I get more information?
Please call our <Member/Customer> Services Department <insert days and hours of operation>, at <insert phone number> if you have any questions. TTY/TDD users should call <insert TTY/TDD phone number>.
You can contact us if you need more information, about:
• How we manage the use of services and costs;
• The number of appeals and grievances filed by our members;
• [A summary description of how we pay our doctors;] or
• A description of our financial condition, including a summary of our most recent audit statement.
You can also get information about the Medicare Program and Medicare plans by visiting www.medicare.gov on the web or by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Customer service representatives are available 24 hours a day, including weekends, to answer your Medicare questions.
We look forward to serving you now and in the future.
Sincerely,
<Plan Representative>
Encl:
[Summary of Benefits]
Formulary
<Material ID number>
<mm/yyyy>
(Source: http://www.cms.hhs.gov/ PrescriptionDrugCovContra/ PartDMMM/itemdetail.asp? itemID=CMS1187112)