an appeal is a formal way of asking us to Medicare at 1-800-MEDICARE (1-800-633-4227). TTY decision.” Making change our coverage decision. You can make an appeal if we users should call 1-877-486-2048. You can call these deny a claim in whole or in part. [Plans with cost sharing insert: numbers for free, 24 hours a day, 7 days a week. You can also make an appeal if we approve a claim but you Medicaid at <phone number>. [Plans must revise disagree with how much you are paying for the drug.] references of to use the State-specific name for “Medicaid” the program.] There are rules for how appeals are handled. These are legal procedures, and the deadlines are important. You can get a [Plans may add contact information for additional fast appeal if your doctor tells us that your health requires a resources such as the State Health Insurance Assistance quick decision. Program (SHIP), ombudsman, etc.] 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. <Plan name> Member Services at <toll-free number>. Updates to our Drug List that will affect drugs you take [Use this section to provide negative formulary updates If an update is for a negative formulary change that is not a that affect drugs the member is taking—that is, any formulary maintenance change, insert: If you are currently drugs the member got during the current calendar taking this drug, this change will not affect your coverage year while a member of the plan. Include updates only if for this drug for the rest of the plan year.] they affect drugs the member is taking and involve About the Drug List negative changes. (Changes to the formulary from one year to the next do not need to be included in the EOB.) [Plan must insert if it sends a hard copy List of Covered Drugs: <Plan name> sent you a List of Covered Drugs or If there are no updates, delete this section. “Drug List”
decision.” Making an appeal is a formal way of asking us to change our coverage decision. You can make an 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 number>. Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. Medicaid at <phone number>. [Plans must revise references of “Medicaid” to use the State-specific name for the program.] [Plans may add contact information for additional resources such as the State Health Insurance Assistance Program (SHIP), ombudsman, etc.] 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. (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 must insert if it sends a hard copy List of Covered Drugs: <Plan name> sent you a List of Covered Drugs or “Drug List”
EOBDrugOnly_CY2018.docx