appeal if we deny a claim in whole or in part. [Plans with cost <Plan name> Member Services at <toll-free phone and sharing insert: You can also make an appeal if we approve a TTY/TDD numbers>, <days and hours of operation>. claim but you disagree with how much you are paying for the Medicare at 1-800-MEDICARE (1-800-633-4227). TTY drug.] should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. There are rules for how appeals are handled. These are legal procedures, and the deadlines are important. You can get a The MyCare Ohio Ombudsman at 1-800-282-1206, fast appeal if your doctor tells us that your health requires a Monday through Friday from 8:00 am to 5:00 pm. TTY quick decision. users should call 1-800-750-0750 for Ohio Relay Service. If you have questions, or if you need help making an appeal, For more information about making an appeal, please see your you can call: Member Handbook. Updates to our Drug List that will affect drugs you take [Use this section to provide negative formulary updates If there are no updates, delete this section. that affect drugs the member is taking—that is, any If an update is for a negative formulary change that is not a drugs the member got during the current calendar formulary maintenance change, insert: If you are currently year while a member of the plan. Include updates only if taking this drug, this change will not affect your coverage they affect drugs the member is taking and involve for this drug for the rest of the plan year.] negative changes, as provided in Section 30.3.4.1 of About the Drug List Chapter 6 of the Prescription Drug Benefit Manual. (Changes to the formulary from one year to the next do not <Plan name> sent you a of Covered Drugs,” or List” “List “Drug need to be included in the EOB.) for short. The Drug List tells which drugs are covered by our
appeal if we deny a claim in whole or in part. [Plans with cost sharing insert: You can also make an appeal if we approve a claim but you disagree with how much you are paying for the drug.] There are rules for how appeals are handled. These are legal procedures, and the deadlines are important. You can get a fast appeal if your doctor tells us that your health requires a quick decision. If you have questions, or if you need help making an appeal, you can call: <Plan name> Member Services at <toll-free phone and TTY/TDD numbers>, <days and hours of operation>. Medicare at 1-800-MEDICARE (1-800-633-4227). TTY should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. The MyCare Ohio Ombudsman at 1-800-282-1206, Monday through Friday from 8:00 am to 5:00 pm. TTY users should call 1-800-750-0750 for Ohio Relay Service. For more information about making an appeal, please see your Member Handbook. Updates to our Drug List that will affect drugs you take [Use this section to provide negative formulary updates that affect drugs the member is taking—that is, any drugs the member got during the current calendar year while a member of the plan. Include updates only if they affect drugs the member is taking and involve negative changes, as provided in Section 30.3.4.1 of Chapter 6 of the Prescription Drug Benefit Manual. (Changes to the formulary from one year to the next do not need to be included in the EOB.) If there are no updates, delete this section. If an update is for a negative formulary change that is not a formulary maintenance change, insert: If you are currently taking this drug, this change will not affect your coverage for this drug for the rest of the plan year.] About the Drug List <Plan name> sent you a “List of Covered Drugs,” or “Drug List” for short. The Drug List tells which drugs are covered by our
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