<Drug name> [Insert name of drug for which cost sharing will We are telling you about these changes now so that you and increase. Plans may also insert information about the strength your doctor will have time (at least 60 days) to decide what to or form in which the drug is dispensed (for example: tablets or do. injectable).] Depending on the type of change, there may be different Date and type of change: Effective [insert effective date options to consider. For example: of the change], [insert description of the change, for You can call Member Services at <toll-free phone and example: the brand-name drug [insert name of drug for TTY/TDD numbers>, <days and hours of operation> to ask which cost sharing will increase] will move from tier 2 to for a list of covered drugs that treat the same medical tier 3.] [Plans with one coverage stage (that is, with no condition. member cost sharing for any Part D drugs), delete the rest of this paragraph:] The amount you will pay for this drug Your doctor be able to find a different drug may change when you fill the prescription depending on covered by the plan. The drug might work just as well for whether you have met your out-of-pocket limit for the year. you and have fewer restrictions [plans with cost sharing for To find out how much you will pay, please call Member any tier of drugs insert: or a lower cost]. Services. You and your doctor can ask the plan to make an Note: See the information later in this section that tells Your doctor will need to tell us why exception for you. you and your doctor can do.” [Plans may add more “What making an exception is medically necessary for you. For information if desired, for example: You and your doctor more information about asking for an exception, call may want to consider trying a lower cost generic drug, Member Services at <toll-free phone and TTY/TDD [insert name of lower-cost generic drug], which is in cost numbers>, <days and hours of operation>. sharing tier [insert number or name of cost sharing tier].] What you and your doctor can do
<Drug name> [Insert name of drug for which cost sharing will increase. Plans may also insert information about the strength or form in which the drug is dispensed (for example: tablets or injectable).] Date and type of change: Effective [insert effective date of the change], [insert description of the change, for example: the brand-name drug [insert name of drug for which cost sharing will increase] will move from tier 2 to tier 3.] [Plans with one coverage stage (that is, with no member cost sharing for any Part D drugs), delete the rest of this paragraph:] The amount you will pay for this drug may change when you fill the prescription depending on whether you have met your out-of-pocket limit for the year. To find out how much you will pay, please call Member Services. Note: See the information later in this section that tells “What you and your doctor can do.” [Plans may add more information if desired, for example: You and your doctor may want to consider trying a lower cost generic drug, [insert name of lower-cost generic drug], which is in cost sharing tier [insert number or name of cost sharing tier].] What you and your doctor can do We are telling you about these changes now so that you and your doctor will have time (at least 60 days) to decide what to do. Depending on the type of change, there may be different options to consider. For example: You can call Member Services at <toll-free phone and TTY/TDD numbers>, <days and hours of operation> to ask for a list of covered drugs that treat the same medical condition. Your doctor be able to find a different drug covered by the plan. The drug might work just as well for you and have fewer restrictions [plans with cost sharing for any tier of drugs insert: or a lower cost]. You and your doctor can ask the plan to make an exception for you. Your doctor will need to tell us why making an exception is medically necessary for you. For more information about asking for an exception, call Member Services at <toll-free phone and TTY/TDD numbers>, <days and hours of operation>.
OHEOB2018.docx