Medicare Part D Plan Medicare Part D Premiums Medicare Part D Forms & Publications Pharmacy Information Pharmacy Directory Order Rx Refills Annual Notice of Change Enrollment Contract Termination MTMP Service Area Grievances, Exceptions, Coverage Determination & Appeal Proceedures Member Rights & Responsibilities Privacy Notice Medicare Website What is disenrollment? Until your prescription drug coverage with our Plan ends, use DEPOT DRUG MAIL and Depot Drug Walk-In Pharmacies to fill your prescriptions What are your options for getting Rx drug coverage if you leave our Plan? When can you disenroll or switch Medicare Prescription Drug Plans? Annual Coordinated Enrollment Period Special Enrollment Period How do you disenroll? When can our Plan disenroll you? If you are no longer eligible for Medicare Prescription Drug coverage If our Plan is no longer contracting with Medicare or leaves your service area If you move out of our Plan’s service area You materially misrepresent third-party reimbursement You fail to pay the plan premium You engage in disruptive behavior, provide fraudulent information when you enrolled, or abuse your UPREHS ID card We cannot ask you to leave our Plan because of your health You have the right to make a complaint if we ask you to leave our Plan What is disenrollment? Disenrollment from our Plan means ending your membership with us. Disenrollment can be voluntary (your own choice) or, in limited circumstances, involuntary (not your own choice). You might leave our Plan because you have decided that you want to leave. You can decide to leave for any reason during specified times. See When can you disenroll or switch Prescription Drug Plans in this section. There are also a few situations where you would be required to leave. For example, you would have to leave our Plan if we no longer offer prescription drug coverage in your geographic area. We are not allowed to ask you to leave our Plan because of your health. Whether leaving our Plan is your choice or not, this section explains your prescription drug coverage choices after you leave and the rules that apply. Back top Top Until your prescription drug coverage with our Plan ends, use our preferred Depot Drug Mail and Depot Drug Walk-In Pharmacies to fill your prescriptions You can choose to disenroll from our Plan from November 15 through December 31 of every year. In certain cases, such as if you enter a nursing home, you can disenroll from our Plan at other times. After you request to disenroll, we will let you know in writing the date your coverage ends. If you don’t get a letter, call Customer Services and ask for the date. Remember if you disenroll from our Plan, you also disenroll from the UPREHS Medicare HCPP & Medicare Secondary Plan, and you may not get another opportunity to enroll again. If you have any questions about your prescription drug coverage with our Plan, please call our Customer Services at 1-800-547-0421. Back top Top What are your options for getting Rx drug coverage if you leave our Plan? If you leave our Plan, one choice for getting prescription drug coverage is to join another Medicare Prescription Drug Plan. You also have the choice of joining a Medicare Advantage Plan or a Medicare Cost Plan with prescription drug coverage if this type of plan is available in your area, they are accepting new members, and you meet the eligibility requirements of their Plan. Medicare Prescription Drug Plan. You may choose to join another Prescription Drug Plan that adds prescription drug benefits to your regular Medicare coverage. To enroll in another Prescription Drug Plan in your area, you must be entitled to Medicare benefits under Part A and/or currently enrolled in Part B, and reside in the service area of the Prescription Drug Plan. Refer to When can you disenroll or switch Medicare Prescription Drug Plans in this section for information on when you can make this change. Medicare Advantage Prescription Drug Plan (MAPD), or Medicare Cost Plan with Prescription Drug Coverage.If you choose to join a Medicare Advantage Plan that offers prescription drug coverage, then you must get your Medicare Prescription Drug coverage through that Medicare Advantage Plan. If you choose to join a Medicare Cost Plan that offers prescription drug coverage, you can get your drug coverage either from the Cost Plan or by joining a separate Medicare Prescription Drug Plan. For more information on joining a Medicare Advantage Plan or a Medicare Cost Plan in your area, please contact 1-800-MEDICARE (TTY/TDD users call 1-877-486-2048) or visit www.medicare.gov. You should contact the new plan that you are interested in for information on how and when you are able to join it. NOTE: If you disenroll from our Plan and do not enroll in another Medicare Prescription Drug Plan, or don’t have other prescription drug coverage that is at least as good as Medicare Prescription Drug coverage, you may have to pay a penalty if you enroll in a Medicare Prescription Drug Plan at a later date. Refer to Section 3 for more information on the penalty. Back top Top When can you disenroll or switch Medicare Prescription Drug Plans? In general, you may only disenroll or switch Medicare Prescription Drug Plans every year during the Annual Coordinated Enrollment Period (see below) or under certain special circumstances. You can switch your Prescription Drug Plan during the following periods. Back top Top Annual Coordinated Enrollment Period During the Annual Coordinated Enrollment Period, anyone with prescription drug coverage may disenroll from any Prescription Drug Plan and join another Prescription Drug Plan, or join a Medicare Advantage Plan with prescription drug coverage, or choose not to have any Medicare Prescription Drug coverage. UPREHS does NOT have an Annual Coordinated Enrollment Period. For coverage beginning in 2010, and afterwards, the Annual Coordinated Enrollment Period begins on November 15, and ends on December 31, of each year. As a UPREHS HCPP & Medicare Secondary Plan member, you are automatically enrolled in the UPREHS Prime Medicare Plan each year. If you choose to disenroll during the Annual Coordinated Enrollment Period, you may not be allowed to join a UPREHS Medicare plan again and you will also lose your UPREHS HCPP & Medicare Secondary Plan membership. If you disenroll from our Plan and do not enroll in another Prescription Drug Plan or Medicare Advantage Plan with prescription drug coverage during this election period, you may have to pay a higher premium for Medicare Prescription Drug coverage in the future. If you join another Prescription Drug Plan during the Annual Coordinated Enrollment Period, your enrollment in our Plan will end on December 31 and your enrollment in the new Plan will be effective on January 1st of the following year. Remember, if you join another plan, you may not be eligible for any UPREHS Medicare Plan again. Back top Top Special Enrollment Period Generally, you may not disenroll from our Plan and enroll in a new Prescription Drug Plan during other times of the year unless you qualify for a Special Enrollment Period. In order to qualify for a Special Enrollment Period, one of the following must apply to you: Our Plan no longer offers prescription drug coverage in the area where you live. You have an involuntary loss of creditable prescription drug coverage. Failure to pay your premium does not qualify as an involuntary loss of prescription drug coverage. You were not adequately informed about your loss of creditable prescription drug coverage, or you were not adequately informed that you never had creditable prescription drug coverage. Your enrollment in our Plan was unintentional, inadvertent, or a mistake, because of the error, misrepresentation or inaction of a Federal employee, or a person acting upon the Federal government’s behalf. Our Plan’s contract with the Centers for Medicare & Medicaid Services is terminated. You were a member of a Medicare Advantage Plan with prescription drug coverage and decided to join a Prescription Drug Plan during the Medicare Advantage Plan’s Open Enrollment Period. You are able to demonstrate that our Plan has substantially violated a material provision in its contract. This includes, but is not limited to: If our Plan failed to provide you with prescription drug coverage in a timely manner; or if you are able to demonstrate that our Plan misrepresented itself in its marketing. You are enrolling in or disenrolling from a Medicare Prescription Drug Plan sponsored by your current or former employer or by your spouse’s current or former employer. In certain cases in which our Plan would be sanctioned by the Centers for Medicare & Medicaid Services. You enroll in or disenroll from your State’s Program of All-Inclusive Care for the Elderly. You move into, live in, or move out of certain medical facilities, including a skilled nursing facility, nursing facility, intermediate care facility for the mentally retarded, psychiatric hospital or unit, rehabilitation hospital or unit, long-term care hospital, or certain other hospitals. You get extra help and the Centers for Medicare & Medicaid Services enrolled you in your current plan. Other limited circumstances may provide a Special Enrollment Period. In the event that you are eligible for a Special Enrollment Period, the Centers for Medicare & Medicaid Services will determine the time frame for you to enroll in another Plan. If you feel you qualify for a Special Enrollment Period, please call Medicare at 1-800-633-4227. Back top Top How do you disenroll? Remember, if you disenroll from the UPREHS Prime Medicare Plan prescription drug plan, you will automatically be disenrolled from the UPREHS HCPP & Medicare Secondary Plan and you may not have another opportunity to join any UPREHS Medicare Plan again. If you are joining another Prescription Drug Plan, you must contact that Plan to request enrollment information. Once you are enrolled in your new Plan, your membership in our Plan will automatically end with no action required on your part. Your new Plan will tell you, in writing, the date when your prescription drug coverage in that Plan begins. Your prescription drug coverage with our Plan will end on that same day (this will be your disenrollment date). Remember, you are still a member of our Plan until your disenrollment date, and must continue to get your prescription drug coverage, as usual, through our Plan until the date your membership ends. If you wish to leave our Plan, and you are not enrolling in another Prescription Drug Plan, you will need to submit a disenrollment request. Your request should include your name, Unique UPREHS ID number (on your ID card), Medicare number, Social Security number, date of birth, and requested disenrollment date. We may not be able to disenroll you on the date you request. Remember to sign and date the request and to include a phone number where we can reach you in case we need additional information. You can mail a letter to us at UPREHS, PO Box 165090, Salt Lake City, UT 84116-5090, or fax it to us at 801-595-2040. To get a copy of our disenrollment form, please call Customer services at 1-800-547- 0421. You may also disenroll by calling 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You may only disenroll during the Annual Coordinated Enrollment Period unless you qualify for a Special Enrollment Period. Back top Top When can our Plan disenroll you? Our Plan can disenroll you for the following reasons: You are no longer eligible for Medicare Prescription Drug coverage. If our Plan is no longer contracting with Medicare or leaves your service area. When you move out of our Plan’s service area. You materially misrepresent third-party reimbursement. You fail to pay your Plan premium. You engage in disruptive behavior, provided fraudulent information when you enrolled, or abuse your UPREHS ID card. If you are no longer eligible for Medicare Prescription Drug coverage If you lose your eligibility for Medicare Prescription Drug coverage, UPREHS can no longer offer you prescription drug coverage. In order to be eligible for prescription drug coverage under Medicare, you must have Part A and/or Part B, and reside in the Plan’s service area. To be eligible for the UPREHS Medicare Plans, you must have Medicare Part A and be enrolled in Part B. Our service area is national. Back top Top If our Plan is no longer contracting with Medicare or leaves your service area If we leave the Medicare program or no longer offer prescription drug coverage in the area where you live, we will notify you in writing. If this happens, your membership in our Plan will end, and you will have to enroll in another Medicare Prescription Drug Plan to continue your prescription drug coverage. All of the benefits and rules described in this Benefit Guide will continue until your membership ends. This means that you must continue to get your prescription drugs through our preferred Depot Drug Mail Pharmacy and Depot Drug Walk-In Pharmacies until your membership ends. Your choices include joining another Medicare Prescription Drug Plan or a Medicare Advantage Plan with prescription drug coverage if these plans are available in your area and are accepting new members. Once we have notified you in writing that we are leaving the Medicare program or the area where you live, you may enroll in another plan. See When can you disenroll or switch Prescription Drug Plans? above for specific information on special enrollment periods. Our Plan has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract may be renewed each year. However, our Plan or CMS can decide to end the contract at any time. You will generally be notified 90 days in advance if this situation occurs. However, your advance notice may be as little as 30 days or even fewer days if CMS must end our contract in the middle of the year. Back top Top If you move out of our Plan’s service area UPREHS Prime Medicare Plan is a national plan. If you move permanently outside of the United States, please call our Customer Services at 1-800-547-0421. If you move permanently out of the United States, you will need to leave (disenroll from) our Plan. An earlier part of this section tells about the choices you have if you leave our Plan and explains how to leave. Back top Top You materially misrepresent third-party reimbursement If you intentionally withhold or falsify information about third-party reimbursement coverage, CMS requires our Plan to disenroll you. In addition, if you are disenrolled from our Plan for misrepresentation of third party reimbursement, our Plan has the right to decline you future enrollment in our Prescription Drug Plan. This disenrollment would include disenrollment from the UPREHS HCPP & Medicare Secondary Plan. Back top Top You fail to pay the plan premium If you fail to pay your Plan premium, we have the right to disenroll you. Our Plan will send you a written notice in an effort to collect the unpaid premium(s). Failure to comply with payment will result in disenrollment from our Plan. In addition, if you are disenrolled from our Plan for failure to pay your premium, we have the right to decline your future enrollment in our Prescription Drug Plan and/or our HCPP & Medicare Secondary Plan until your debt has been paid. If you are disenrolled due to not paying your premium and you do not have drug coverage that, on average, is at least as good as standard Medicare Prescription Drug coverage for 63 days or longer, then you will pay a penalty the next time you enroll in a Medicare Prescription Drug Plan. Back top Top You engage in disruptive behavior, provide fraudulent information when you enrolled, or abuse your UPREHS ID card You may be asked to leave our Plan in the following circumstances: If you behave in a way that seriously affects our ability to arrange or provide services for you or for others who are members of our Plan we can ask you to leave our Plan. We cannot make you leave (disenroll from) our Plan for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare. If you give us information on your enrollment form that you know is false or deliberately misleading, and it affects whether or not you can enroll in our Plan. If you let someone else use your (Plan membership) UPREHS ID card to get prescription drugs for themselves or for others. Before we ask you to leave (disenroll from) our Plan for this reason, we must refer your case to the Inspector General, and this may result in criminal prosecution. Back top Top We cannot ask you to leave our Plan because of your health No member of any Medicare Prescription Drug Plan can be asked to leave any Plan for any healthrelated reasons or the number of prescriptions a member takes. If you ever feel that you are being encouraged or asked to leave our Plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227; TTY/TDD 1-877-486-2048), the national Medicare help line. Back top Top You have the right to make a complaint if we ask you to leave our Plan If we ask you to leave our Plan, we will tell you our reasons in writing and explain how you can file a complaint against us if you want. Refer to Section 6 for more information. 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