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
<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>.