EOC VIP RX CH
EmblemHealth
PDF
EOC VIP RX CH 2021 1 1 2021 12 31
(VIP Rx) (PDP) Medicare
2021 1 1 2021 12 31 Medicare
(VIP Rx) (EmblemHealth Plan, Inc.) """" (EmblemHealth Plan, Inc.)"""" (VIP Rx) (PDP)
1-877-444-7241 TTY 711 7 8:00 am 8:00 pm
// 2022 1 1
/
S5966_201466_C
86-100671-21CH
OMB 0938-1051 2021 12 31
(VIP Rx) 2021
1
2021
1
.........................................................................................................4
Medicare D
2
...........................................................................................22
(VIP Rx(Medicare) (SHIP) (Medicaid)
3
D ......................................................41
D
4
D ......................................................................65
D 5
5
...........................................................84
(VIP Rx) 2021
2
6
...................................................................................................90
7
.............................................................................100
/
8
.....................................................................................126
9
.............................................................................................................137
10 ..........................................................................................................140
1
(VIP Rx) 2021
4
1
1 1.1
1.2 1.3
2 2.1 2.2 2.3 2.4
3 3.1 3.2 3.3 3.4
4 4.1
5 5.1 5.2 5.3 5.4
6 6.1 6.2 6.3
1
.................................................................................................................. 6 (VIP Rx) (Medicare) ...................................... 6 ............................................................ 6 ............................................................................. 6
.......................................................................... 7 ................................................................................................. 7 A B ....................... 7 (VIP Rx) .... 8 ..................................................................................... 8
.......................................................... 8 ................................. 8 .................................................... 9 ........................................................... 10 D "D EOB" D ....................................................................................... 10
(VIP Rx) ................... 10 ............................................................................... 10
D "" ................................................... 11 D ""................................................................... 11 D ................................................................... 12 ............................... 13 D ...................................... 13
D ................................... 14 D .............................................. 14 D ........................................................................... 14 D ...................................... 14
(VIP Rx) 2021
5
1
6.4
D .................................. 14
7
............................................................................ 15
Medicare ......................... 15
7.1
............................................................... 15
7.2
.......................................... 17
8
............................................................ 18
8.1
....................................................... 18
............................................................. 18
......................................... 18
9 9.1
........................................................ 19 ........................................................... 19
10 10.1
................................................................ 19 ................................................... 19
(VIP Rx) 2021
6
1
1
1.1
(VIP Rx) (Medicare)
Medicare) ---- (VIP Rx)---- (Medicare)
Medicare (VIP Rx)(Medicare) (PDP) MedicareMedicare Medicare
1.2
(Medicare)
"""" (VIP Rx)
1.3
(VIP Rx)
(VIP Rx) 2021
7
1
""""
2021 1 1 2021 12 31 (VIP Rx)
Medicare 2021 12 31 (VIP Rx) 2021 12 31
Medicare
(Medicare) (VIP Rx) (Medicare) (Medicare)
2
2.1
A B A B 2.2 A B
-------- -------- 2.3
2.2
A B
1.1 D (Medicare) (Medicare) 3 D
(VIP Rx) 2021
8
1
Medicare A B
A
B (DME)
2.3
(VIP Rx)
(Medicare) (VIP Rx)
(Medicare)
2 5
2.4
Medicare (Medicare ) (VIP Rx) (VIP Rx)
3
3.1
Medicaid
(VIP Rx) 2021
9
1
(Medicare) (Medicare )
3.2
""
2021 emblemhealth.com/medicare /
emblemhealth.com/medicare
(VIP Rx) 2021
10
1
3.3
"" D (VIP Rx) Medicare Medicare (VIP Rx)
(emblemhealth.com/medicare)
3.4
D "D EOB" D
D D D "D EOB"
D D D D EOB 4 D D
D
4
(VIP Rx)
4.1
2021 (VIP Rx) $49.30 B B Medicaid
(VIP Rx) 2021
11
1
"" 2 7
" """"LIS " "LIS "
4.1 D (Medicare ) 63 "" ""(Medicare) D D
D D 1 5 D
D
D (IRMAA) 2 IRMAA 1 6 IRMAA
5
D ""
5.1
D ""
Medicare""
(VIP Rx) 2021
12
1
D 63 D D ""Medicare Medicare D D
D (VIP Rx)
D D
5.2
D
Medicare
Medicare 63 1% 14 14%
Medicare Medicare2021 $33.06
10 $33.06 14% $4.6284 $4.60 D
D
Medicare
D
65 Medicare D 65 65 D
(VIP Rx) 2021
13
1
Medicare
5.3
D D
Medicare" "
o Medicare
"" "" Medicare
o
o 2021 (Medicare & You) (Medicare ) 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048 7 24
63
Medicare""
5.4
D
D 60
(VIP Rx) 2021
14
1
D
6
D
6.1
D
2 IRS (IRMAA)IRMAA
Medicare (RRB) Medicare
6.2
D
IRS (MAGI) www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html
6.3
D
1-800-772-1213 TTY 1-800-325-0778
6.4
D
D Medicare
(VIP Rx) 2021
15
1
7
Medicare
Medicare A A B
2 IRS (IRMAA)IRMAA
Medicare
D 1 6 www.medicare.gov 7 24 1-800MEDICARE (1-800-633-4227) TTY 1-877486-2048 1-800-772-1213 TTY 1-800-325-0778
2021 (Medicare & You) "2021 Medicare) "Medicare B D Medicare (Medicare & You) Medicare Medicare (www.medicare.gov) (Medicare & You) 2021 1-800MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
7.1
(VIP Rx) 2021
16
1
1 2 3 1 Medicare Medicaid (CMS)
EmblemHealth P.O. Box 21613 New York, NY 10087-1613
2 emblemhealth.com/medicare "Pay My Bill" VisaMasterCard 7 24
3 (EIVR) VISA MasterCard EIVR 7 24
4 VisaMasterCardDiscover Card emblemhealth.com/medicare
(VIP Rx) 2021
17
1
5
90
Medicare
D Medicare 63 "" D D
7 7 1-877-444-7241 7 8:00 am 8:00 pm TTY 711 60
7.2
9 1 1
(VIP Rx) 2021
18
1
"""" """" 2 7 ""
8
8.1
Medicaid
)
2 5
10
(VIP Rx) 2021
19
1
9
9.1
6 1.3
10
10.1
Medicare " """
Medicare
(ESRD) Medicare
o 65 100 100
o 65 20 20
(VIP Rx) 2021
20
1
Medicare Medicare 30
Medicare Medicaid Medicare/
2
(VIP Rx) 2021
22
2
1 2 3 4
5 6 7 8 9
2
(VIP Rx) ......................................... 23
(Medicare) (Medicare) .......................................... 27
Medicare ................................................. 29
Medicare Medicare ............................................................................................................. 30
.................................................................................................... 31
Medicaid ............................. 32
............................................ 33
.................................................................... 38
"" .................................... 39
(VIP Rx) 2021
23
2
1
(VIP Rx)
(VIP Rx)
1-877-444-7241 7 8:00 am 8:00 pm
TTY
711 7 8:00 am 8:00 pm
1-212-510-5373
EmblemHealth Pharmacy Services PO Box 1520 JAF Station New York, NY 10116-1520
emblemhealth.com/medicare
(VIP Rx) 2021
24
2
D
D D 7
D
TTY
1-877-920-1470 7 24 1-800-716-3231
7 24 1-877-251-5896
Express Scripts Attn: Medicare Reviews P.O. Box 66571 St. Louis, MO 63166-6571
www.express-scripts.com
(VIP Rx) 2021
25
2
D
D 7
D
TTY
1-877-444-7241 8:00 am 6:00 pm 1-888-447-6855
711 7 8:00 am 8:00 pm
1-212-510-5320 1-866-350-2168
EmblemHealth Medicare PDP Attn: Grievance & Appeals P.O. Box 2807 New York, NY 10116-2807
emblemhealth.com/medicare
D
D 7
(VIP Rx) 2021
26
2
D
1-877-444-7241 7 8:00 am 8:00 pm
711
TTY
7 8:00 am 8:00 pm
1-212-510-5320
Medicare
EmblemHealth Medicare PDP Attn: Grievance & Appeals P.O. Box 2807 New York, NY 10116-2807
(VIP Rx) Medicare Medicare www.medicare.gov/MedicareComplaintForm/home.aspx
5 )
7
(VIP Rx) 2021
27
2
Express Scripts ATTN: Medicare Part D P.O. Box 14718 Lexington, KY 40512-4718
www.express-scripts.com
2
(Medicare) (Medicare)
Medicare 65 65
MedicareMedicare MedicaidCenters for Medicare & Medicaid Services"CMS"(Medicare )
Medicare
1-800-MEDICARE 1-800-633-4227 7 24
TTY
1-877-486-2048
(VIP Rx) 2021
28
2
Medicare
www.medicare.gov
MedicareMedicare Medicare
Medicare Medicare
Medicare (Medicare Eligibility Tool) Medicare
Medicare (Medicare Plan Finder) Medicare Medicare Medicare Medicare
(VIP Rx) 2021
29
2
Medicare
Medicare (VIP Rx)
Medicare (VIP Rx) Medicare Medicare www.medicare.gov/MedicareComplaintForm/home.aspx Medicare Medicare
Medicare Medicare 1-800-MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
3
Medicare
(SHIP) (New York) SHIP (HIICAP)
(HIICAP) Medicare
(HIICAP) Medicare Medicare Medicare (HIICAP)
(VIP Rx) 2021
30
2
Medicare
(HIICAP) (New York's SHIP)
1-800-701-0501
TTY
711
New York State Office for the Aging 2 Empire State Plaza Albany, New York 12223-1251
www.aging.ny.gov
4
Medicare Medicare
Medicare Livanta
Livanta MedicareMedicare Livanta
Livanta Livanta
(VIP Rx) 2021
31
2
Livanta-
1-866-815-5440 9 am 5 pm
TTY
1-866-868-2289
Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701
www.livanta.com
5
Medicare 65 Medicare Medicare Medicare MedicareMedicare
D
(VIP Rx) 2021
32
2
1-800-772-1213
7:00 am 7:00 pm 24
TTY
1-800-325-0778 7:00 am 7:00 pm
https://www.ssa.gov/ https://www.ssa.gov/
6
Medicaid
Medicaid Medicare (Medicaid)
Medicaid MedicareMedicare Medicare""
Medicare (QMB) A B QMB Medicaid (QMB+)
Medicare (SLMB) B SLMB Medicaid (SLMB+)
(VIP Rx) 2021
33
2
(QI) B (QDWI) A
Medicaid (New York)
(New York) Medicaid
TTY
1-800-541-2831 9:00 am 5:00 pm
711
New York State Department of Health Corning Tower Empire State Plaza Albany, NY 12237
https://www.health.ny.gov/health_care/medicaid/
7
Medicare""
(Medicare)"" (Medicare) ""
"""" Medicare" "
"" ""
(VIP Rx) 2021
34
2
1-800-MEDICARE (1-800-633-4227) TTY 1877-486-2048 7 24
1-800-772-12137 am 7 pm TTY 1-800-325-0778
Medicaid 6
""
EmblemHealth AttentionMedicare Enrollment P.O. Box 2859 New York, NY 10117-7894 (Medicare) Medicaid 6
6 Medicaid
6 Medicaid
6 Medicaid
"...... ......"
LIS SSA
(VIP Rx) 2021
35
2
(HCBS) HCBS 6
HCBS 6 (Medicaid)
HCBS 6 (Medicaid)
HCBS (Medicaid) 6 (Medicaid)
HCBS HCBS 6
HCBS HCBS 6
HCBS 6 HCBS
HCBS HCBS HCBS
(Medicare)
(VIP Rx) 2021
36
2
Medicare
(Medicare) "" D 70% 25%
D (EOB) (5%)
75% 25% (75%)
Medicare
(SPAP)
(SPAP) D "" 70% 5% 70% 5% SPAP
(AIDS Drug Assistance Program, ADAP) (ADAP)
(ADAP) (HIV)/ ADAP HIV ADAP D HIV Uninsured Care Program ADAP (HIV) /
(VIP Rx) 2021
37
2
ADAP ADAP D D 1-800-542-2437 1518-459-1641 ADAP TTY 1-518-459-0121
1-800-542-2437 1-518-459-1641 HIV Uninsured Care Program TTY 1-518-459-0121
HIV Uninsured Care Program
1-800-542-2437 1-518-459-1641
TTY
1-518-459-0121
New York State HIV Uninsured Care Program Empire Station P.O. Box 2052 Albany, NY 12220-0052
http://www.health.ny.gov/diseases/aids/general/resources/adap
Medicare""
""
D D EOB D (SHIP)
(VIP Rx) 2021
38
2
3 1-800-MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
(EPIC)
(EPIC)
TTY
1-800-332-3742 8:30 am 5:00 pm
1-800-290-9138
EPIC P.O. Box 15018 Albany, NY 12212-5018
http://www.health.ny.gov/health_care/epic/
8
Medicare
(VIP Rx) 2021
39
2
(RRB)
1-877-772-5772
"0" 9:00 am 3:30 pm 9:00 am 12:00 pm (RRB)
"1" 24 (RRB)
TTY
1-312-751-4701
rrb.gov/
9
""
/ Medicare 1-800-MEDICARE1-800-633-4227 TTY
1-877-486-2048
3
D
(VIP Rx) 2021
41
3
D
3
D
1 1.1 1.2
................................................................................................................ 43 D ...................................................... 43 D .................................................. 43
2 2.1 2.2 2.3 2.4 2.5
.................................... 44 ....................................................... 44 ............................................................................................... 44 ................................................................................... 45 ....................................................................... 46 ............................................... 47
3 3.1 3.2 3.3
"" ............................................................ 48 "" D ................................................... 48 5 "" ............................................... 49 ....................................................... 49
4 4.1 4.2 4.3
............................................................................ 49 ............................................................................... 49 ........................................................................................... 50 ....................................................................... 51
5 5.1 5.2 5.3
................................ 51 ............... 51 ....................... 52 ............... 53
6 6.1 6.2
................................ 54 ................................................................................... 54 ........................... 55
7 7.1
................................................................................ 56 ............................................................................... 56
(VIP Rx) 2021
42
3
D
8 8.1 8.2
.................................................... 58 ........................................................................................... 58 ........................................................... 58
9 9.1
9.2 9.3
9.4
9.5 9.6
D ............................................................... 58 Medicare ) ............................................................. 58 (LTC) ....................................... 59
Medicare ................................................................................................... 59 Medicare ........................ 60 ... 60
Medicare ........................................................................................... 61
10 10.1 10.2 10.3
................................................................ 61 ........................................................................... 61 (DMP)........................... 62 (MTM) ............. 62
(VIP Rx) 2021
43
3
D
"" 2 7
D " "" ""LIS " "LIS "
1
1.1
D
D D 4 D )
D Medicare A B
A
B B
Medicare (Medicare & You) D
1.2
D
(VIP Rx) 2021
44
3
D
Medicare CMS / D
2 )
"" 3 "")
"" 3
2
2.1
2.5
"" D
2.2
(emblemhealth.com/medicare)
(VIP Rx) 2021
45
3
D
emblemhealth.com/medicare
(LTC)
LTC LTC D LTC LTC D // FDA (
2.3
"MO"""
30 90
(VIP Rx) 2021
46
3
D
14 90
1-877-8665828
1-877-866-5828
/
1-877-866-5828
30
1-877-866-5828
2.4
""""
(VIP Rx) 2021
47
3
D
2.3
1.
2. "MO""" 30 90 2.3
2.5
D 1 2.3
D 1 2.3
D D
D
D
B
(VIP Rx) 2021
48
3
D
5 2.1
3
""
3.1
"" D
""""
MedicareMedicare
D 1.1 D
""
-------- DRUGDEX
(VIP Rx) 2021
49
3
D
Medicare 7.1
3.2
5 ""
1 - 2 - 3 - 4 - 5 -
4 D )
3.3
1. 2. emblemhealth.com/medicare 3.
4
4.1
(VIP Rx) 2021
50
3
D
Medicare
7 5.2
10 100
4.2
""
""
A B A A B ""
(VIP Rx) 2021
51
3
D
4.3
emblemhealth.com/medicare
7 5.2
5
5.1
4
5
(VIP Rx) 2021
52
3
D
5.2
5.3
5.2
1.
-------- 4
2.
90 90 30 30
90 (LTC)
(VIP Rx) 2021
53
3
D
31 ,
72
7 5.4 Medicare
5.3
(VIP Rx) 2021
54
3
D
7 5.4 Medicare
5
6
6.1
1 1
4
Medicare
(VIP Rx) 2021
55
3
D
6.2
o
o --
o 7 )
o
o
o
(VIP Rx) 2021
56
3
D
o FDA Medicare 30 30
o
o 7 )
1 1
1 1 1 1
7
7.1
""Medicare
D 7 5.5
(VIP Rx) 2021
57
3
D
Medicare D
D A B
""
o "" DRUGDEX ""
Medicare
""Medicaid Medicare Medicaid 2 6 Medicaid
(VIP Rx) 2021
58
3
D
8
8.1
8.2
5 2.1
9
D
9.1
Medicare )
Medicare A
Medicare A A
8 Medicare
(VIP Rx) 2021
59
3
D
9.2
(LTC)
(LTC)
(LTC)
90 31 90 31
7 5.4
9.3
Medicare
(VIP Rx) A B A B A B A B
B (VIP Rx) B B (VIP Rx)
(VIP Rx) 2021
60
3
D
9.4
Medicare
"" "" (Medicare)
9.5
""
""
"" Medicare
D Medicare
(VIP Rx) 2021
61
3
D
9.6
Medicare
Medicare
Medicare D 4 D
10
10.1
(VIP Rx) 2021
62
3
D
10.2
(DMP)
(Drug Management ProgramDMP)
7
DMP
10.3
(MTM)
(MTM)
TMT
(VIP Rx) 2021
63
3
D
""
4
D
(VIP Rx) 2021
65
4
D
1 1.1 1.2
2
2.1
3
3.1 3.2 4
4.1
5
5.1 5.2 5.3
5.4 5.5 6
6.1 6.2
4
D
................................................................................................................ 67 ........................... 67 ........................................................... 68
" " ...................................................................................................... 68
(VIP Rx) ............................................................................................................... 68
..................................................................................................................... 70 "D ""D EOB" ... 70 ....................................................... 70
1 2 3 4 5 ................................................................................ 71
1 2 3 4 5 $445 ....................................................... 71
........................................................................................ 72 ............... 72 ........................................................... 73 ........................................................................................... 74 90 ............................................. 75 $4,130 ...... 76
25% ................................................................................................... 77
$6,550 .............................. 77
Medicare ................................................................................................................... 78
(VIP Rx) 2021
66
4
D
7 7.1
8
8.1
8.2
........................ 80 ... 80
D ............................................................................................................ 80 D ................................................................................................... 80 ........................................... 82
(VIP Rx) 2021
67
4
D
"" 2 7
D " "" ""LIS " "LIS "
1
1.1
D " " D 3 D - A B (Medicare )
""
o
o 5 ""
o emblemhealth.com/medicare
3 3 3
(VIP Rx) 2021
68
4
D
3
1.2
""
""
"" ""
2
" "
2.1
(VIP Rx)
(VIP Rx) " "
(VIP Rx) 2021
69
4
D
1
2
3
4
1 2 3 4 5
"" $4,130
5
1 2 3 4 5 $445$445 1 2 3 4 5
25% 25%
" " $6,550 Medicare
2021 12 31 7
6
4
(VIP Rx) 2021
70
4
D
3
3.1
"D ""D EOB"
"" ""
D "D EOB"D EOB
1 1 ""
3.2
(VIP Rx) 2021
71
4
D
5 2
o
o
o
(ADAP)
D "D EOB"
4
1 2 3 4 5
4.1
1 2 3 4 5 $445
2021 $445
""
"" D
1 2 3 4 5 $445
(VIP Rx) 2021
72
4
D
5
5.1
5
1 - 2 - 3 - 4 - 5 -
3
(VIP Rx) 2021
73
4
D
5.2
"" ""
3 2.5
(VIP Rx) 2021
74
4
D
D
1
2
3
4
5
30
30
30
$7
$2
$0
$17
$12
$12
$45
$40
$40
33%
33%
33%
25%
25%
25%
(LTC)
31
$7
5 30
$7
$17
$17
$45
$45
33%
33%
25%
25%
5.3
(VIP Rx) 2021
75
4
D
o 30 $30 $1 7 $1 7 $7
5.4
90
"") 90 5 2.4
90
(VIP Rx) 2021
76
4
D
D
1
2
3
4
5
90 $21
$51
$135
33%
5
90
$6
90
$0
$36
$30
$120
$120
33%
33%
5
5
5.5
$4,130
$4,130
D
Medicare 6.2
o $445
o
2021 D
(VIP Rx) 2021
77
4
D
(EOB) $4,130
$4,130
6
25%
6.1
$6,550
Medicare 25%
25% (75%)
25% Medicare 2021 $6,550
Medicare $6,550
(VIP Rx) 2021
78
4
D
6.2
Medicare
Medicare
D 3
o o o
Medicare
Medicare Medicare""
Medicare
$6,550
(VIP Rx) 2021
79
4
D
D A B
Medicare Medicare
D D EOB 3 $6,550
3.2
(VIP Rx) 2021
80
4
D
7
7.1
$6,550
o 5% o $3.70 $9.20
8
D
8.1
D
D
""
D
D
1. ) o D o (Medicare )
(VIP Rx) 2021
81
4
D
2. 3.
D
D )
1
D
2
D
5 )
""
3
D
5
(VIP Rx) 2021
82
4
D
" "
8.2
5
(VIP Rx) 2021
84
5
5
1 1.1
.................... 85 ................................................................................................... 85
2 2.1
................................................................ 86 ................................................................... 86
3 3.1 3.2
.................................... 87 ....................................... 87 ....................................................................................................... 87
4 4.1
.................................... 87 ........................................................................................................... 87
(VIP Rx) 2021
85
5
1
1.1
""
7
1.
3 2.5
2.
3.
4.
(VIP Rx) 2021
86
5
7
2
2.1
(emblemhealth.com/medicare)
Express Scripts ATTN: Medicare Part D P.O. Box 14718 Lexington, KY 40512-4718
120
(VIP Rx) 2021
87
5
3
3.1
3 D 30
3.2
7 7 4 4 "" 4 7 5.5
4
4.1
(VIP Rx) 2021
88
5
1.
2.
6
(VIP Rx) 2021
90
6
1 1.1
1.2 1.3 1.4 1.5 1.6 1.7
1.8
2 2.1
6
................................................ 91 ............................................... 91 ........................................................... 91 ................................................... 92 ... 93 ............................................... 94 ................................... 95 ............................................................................................................... 95 ........................................................... 96
........................................................................ 97 ........................................................................................... 97
(VIP Rx) 2021
91
6
1
Section 1.1
We must provide information in a way that works for you (in languages other than English, in braille, in large print, or other alternate formats, etc.)
To get information from us in a way that works for you, please call Customer Service (phone numbers are printed on the back cover of this booklet).
Our plan has people and free interpreter services available to answer questions from disabled and non-English speaking members. Information is available for free in other languages. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan's benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Customer Service (phone numbers are printed on the back cover of this booklet.)
If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Customer Service (phone numbers are printed on the back cover of this booklet). You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights. Contact information is included in this Evidence of Coverage or with this mailing, or you may contact our plan's Customer Service for additional information.
1.1
1-800-MEDICARE (1-800-633-4227) Medicare
(VIP Rx) 2021
92
6
1.2
D 7 7 7 4
1.3
""
""
o
o Medicare Medicare D Medicare
(VIP Rx) 2021
93
6
)
1.4
(VIP Rx) 1.1
Medicare
o
o
o ) emblemhealth.com/medicare
o D 3 4
o
(VIP Rx) 2021
94
6
o D
o D 7 7
o D 5
1.5
"" """"
""
Medicare
(VIP Rx) 2021
95
6
1-800-804-5447 1-800-663-6114
1.6
7
1.7
(VIP Rx) 2021
96
6
1-800-368-1019 TTY 1-800-537-7697
2 3
Medicare 1-800MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
1.8
2 3
(Medicare)
o Medicare Medicare(Medicare Rights & Protections) www.medicare.gov/Pubs/pdf/11534Medicare-Rights-and-Protections.pdf
o 1-800-MEDICARE (1-800-633-4227) 7 24 TTY 1-877-4862048
o
(VIP Rx) 2021
97
6
2
2.1
o 3 4 D
o Medicare "" 1 10
D
o
o
o
o
(VIP Rx) 2021
98
6
o 4 D
o
7
o
o D
o 1 Medicare
o
o 2
o
o 2
7
(VIP Rx) 2021
100
7
7
1 1.1 1.2
.............................................................................................................. 102 ..................................................................... 102 ............................................................................................. 102
2 2.1
...................................... 103 ................................................................. 103
3 3.1
.................................................. 103 ......................................................................................................... 103
...................................................................................................................... 104
4 4.1 4.2
.................................................................. 104 ............................................................. 104 ..................................... 105
5 5.1
5.2 5.3 5.4 5.5
5.6
D ......................... 106 D D ................................................................................. 106 ..................................................................................... 108 ................................................................. 110 ..................................... 111 1 ................................................................................................. 114 2 ............................................................. 116
6 6.1
3 .................................................................................. 118 D 34 5 ........................................... 118
(VIP Rx) 2021
101
7
7 7.1 7.2 7.3 7.4 7.5
....................................................................................................................... 120
.......................... 120 ................................................................. 120 """" .............................................................. 121 ......................................................................................... 122 ......................................... 123 ..................... 124
(VIP Rx) 2021
102
7
1
1.1
Medicare
3
1.2
""""""""" """""
(VIP Rx) 2021
103
7
2
2.1
(SHIP)
SHIP 2 3
Medicare
Medicare Medicare
1-800-MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
Medicare (www.medicare.gov)
3
3.1
(VIP Rx) 2021
104
7
4 ""
7 " "
4
4.1
Medicare Medicare
(VIP Rx) 2021
105
7
""
1 ""
1 2 2 2
4.2
2
D 1 2 2
""
o
o "" Medicare www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf emblemhealth.com/medicare
(VIP Rx) 2021
106
7
5
D
4 )
5.1
D D
" " 3 3
D "" """D "
D 3 D 4 D)
D
4
D " "
D
(VIP Rx) 2021
107
7
o D
o
o
o
(VIP Rx) 2021
108
7
5.2
5.4
5.4
5.5
5.2
""
(VIP Rx) 2021
109
7
1. D ""
"" 5
2. 3
"" o o " " o "" o
3. 5
" "
(VIP Rx) 2021
110
7
o
o
o
5
5.3
""
5.5
(VIP Rx) 2021
111
7
5.4
1 ""
2 1 " D " " "
4
5 5
"" "" 5.2 5.3
(CMS)
""
""""
(VIP Rx) 2021
112
7
"""" 72 24
o ""
o
" "
""
o
o
o "" """" 24 7
2
""
24
o 24 24
o 2 2
(VIP Rx) 2021
113
7
24
"" 72
o 72 72
o 2 2
-- o 72
"" 14
o 2 2
14
3
(VIP Rx) 2021
114
7
5.5
1
D ""
1 1 " "
o 2 1 D
2 1 D
2 1 D
Medicare (CMS)
60
o
o
(VIP Rx) 2021
115
7
""
""""
""
"" 5.4 ""
2
"" 72
o 72 2 2
72
"" 7
""
o 7 2 2
(VIP Rx) 2021
116
7
-- o 7 o 30
14
o 14 2 2
30
3
2
5.6
2
2
""" " (Independent Review Entity) "IRE"
(VIP Rx) 2021
117
7
1 2
1 2 2
""
2
Medicare Medicare D
2 "" "" "" 72
2
24
2 "" 2
7 2 14 2 72
30
(VIP Rx) 2021
118
7
""""
"" 3 3 2
3
2 3 5 2
3 3 6 34 5
6
3
6.1
D 34 5
1 2
2 3
(VIP Rx) 2021
119
7
3
72 24 30
o
o
4
Medicare
72 24 30
o
o 5
5
(VIP Rx) 2021
120
7
7
4
7.1
""
o
(VIP Rx) 2021
121
7
4 6
""""
7.2
""""
""" "
""" "
""" "
(VIP Rx) 2021
122
7
7.3
1
1-877-444-7241 7 8:00 am 8:00 pm TTY 711)
)
60
EmblemHealth Medicare - PDP ATTN: Grievance and Appeals PO Box 2807 New York, NY 10116-2807
1-877-444-7241 TTY 711
8 am 8 pm
""(Appointment of Representative Form) "" Medicare /www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms1696.pdf emblemhealth.com/medicare 44
Medicare 15
(VIP Rx) 2021
123
7
30 14
24
60
"""" """" 24
""" "
2
30 14 44
7.4
(VIP Rx) 2021
124
7
o Medicare
o 2 4
7.5
(VIP Rx) (Medicare)Medicare www.medicare.gov/MedicareComplaintForm/home.aspx(Medicare ) (Medicare )
1-800MEDICARE (1-800-633-4227) TTY/TDD 1-877486-2048
8
(VIP Rx) 2021
126
8
1 1.1
2 2.1 2.2 2.3
3 3.1
4 4.1
5
5.1 5.2 5.3
8
.............................................................................................................. 127 ................................................................. 127
.............................................................. 127 ................................................. 127 ............................. 128 ......... 130
.......................................................................... 131 ............................. 131
.......... 133 ......................................... 133
(VIP Rx) .......................................................................................... 133 ......................................................... 133 ......... 135 ............................................. 135
(VIP Rx) 2021
127
8
1
1.1
(VIP Rx)
o 2 o 3
5
D
2
2.1
""
10 15 12 7
o Medicare o Medicare
Medicare
(VIP Rx) 2021
128
8
Medicare"" MedicareMedicare
o Medicare MedicareMedicare A B Medicare D
Medicare (VIP Rx) D (Medicare ) (Medicare) Cost (VIP Rx) Medicare
Medicare 63 Medicare" "Medicare 1 5
1 1
2.2
(VIP Rx)
MedicareMedicare (www.medicare.gov)
o
(VIP Rx) 2021
129
8
o Medicaid
o ""Medicare
o
o (LTC)
o (PACE)
o 3 10
Medicare 1-800-MEDICARE (1-800-633-4227) 7 24 TTY 1-877-4862048 Medicare
o Medicare
o Medicare Medicare
Medicare"" Medicare MedicareMedicare
o Medicare MedicareMedicare A B Medicare D
Medicare (VIP Rx) D (Medicare
(VIP Rx) 2021
130
8
) (Medicare) Cost (VIP Rx) Medicare
Medicare 63 Medicare D ""Medicare 1 5
2.3
(Medicare & You) 2021
o Medicare (Medicare & You) Medicare
o Medicare (www.medicare.gov) Medicare
Medicare 1-800MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
(VIP Rx) 2021
131
8
3
3.1
2 Medicare
Medicare Medicare
MedicareCost (VIP Rx) Medicare
--------Medicare 1-800MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
Medicare 63 Medicare D "" Medicare 1 5
(VIP Rx) 2021
132
8
10 15 12 7
Medicare
Medicare
(VIP Rx)
Medicare 12 7
Medicare
Medicare
(VIP Rx)
D Medicare MedicareCost (VIP Rx) (Medicare) Medicare 1-800MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048
(VIP Rx) 2021
133
8
Medicare
Medicare Medicare
Medicare 63
1-800-MEDICARE (1-800633-4227) 7 24 TTY 1-877-4862048
Medicare
1 5
4
4.1
(VIP Rx) Medicare 2
:
5
(VIP Rx)
5.1
(VIP Rx)
(VIP Rx) 2021
134
8
A B 12
o
Medicare Medicare Medicare
o Medicare
90 o 90
D Medicare
(VIP Rx) 2021
135
8
5.2
(VIP Rx)
1-800-MEDICARE (1-800-633-4227)Medicare TTY 1-877-486-2048 7 24
5.3
7 7
9
(VIP Rx) 2021
137
9
1 2 3
9
.................................................................................................. 138
.................................................................................................. 138
Medicare ................................................................................................................... 138
(VIP Rx) 2021
138
9
1
XVIII Medicare Medicaid (Centers for Medicare & Medicaid Services, CMS)
2
Medicare 1964 VI 1973 1975 1557
1-800-368-1019 TTY 1-800-537-7697)
3
Medicare
Medicare Medicare CMS 42 CFR 422.108 423.462 (VIP Rx) Medicare 42 CFR 411 B D CMS
(VIP Rx) 2021
139
9
10
(VIP Rx) 2021
140
10
10
7
MedicareMedicare 10 15 12 7
D $6,550
MedicareMedicaid (CMS) Medicare 2 CMS
20%
- """" ""
"copay" $10 $20
(1) (2) ""(3) "" ""
5
(VIP Rx) 2021
141
10
"" 7
Medicare Medicare Medicare
2
"" $30 30 "" $1 $1
(EOC)
)
(VIP Rx) 2021
142
10
Medicare Medicare
(FDA) ""
-
(IRMAA) - 2 IRS (IRMAA) IRMAA Medicare 5%
$4,130
Medicare A B 65 Medicare 7 65 3 65 65 3
""
(LIS) ""
Medicaid Medicaid MedicareMedicaid 2 6 Medicaid
(VIP Rx) 2021
143
10
3 3
Medicare 65 65 Medicare MedicareMedicareCost (PACE) Medicare Advantage, Medicare
Medicare Advantage, (MA) C Medicare A B Medicare Advantage, HMOPPO (Private Fee-for-Service, PFFS) Medicare (Medicare Medical Savings Account, MSA) (Medicare Advantage Medicare Medicare Medicare Advantage, D Medicare Advantage, A B
Medicare D D ""
Medicare A B
Medicare Medicare Medicare A B Medicare Medicare Advantage, MedicareCost / (PACE)
(VIP Rx) 2021
144
10
Medicare D A B
""Medicare Medicare Medicare"" MedicareMedicare Advantage,
"" Medicare MedicareMedicaid (CMS)
""
Medicare"Medicare """Medicare MedicareMedicare Advantage, Medicare Medicare Medicare MedicareMedicare (Medicare) A B
"" ""
PACE - PACE (LTC)
(VIP Rx) 2021
145
10
(PACE) MedicareMedicaid
C - "Medicare Advantage, (MA) "
D Medicare D
D D D D
D D 63 Medicare Medicare Medicare"" ""
D
Medicare
"" 4 ""
(QIO) Medicare 2 4 QIO
(VIP Rx) 2021
146
10
Medicare ""
(SSI) 65 SSI
(VIP Rx)
1-877-444-7241 8 am 8 pm 7
TTY
711
7 8:00 am 8:00 pm
1-212-510-5373
EmblemHealth Pharmacy Services PO Box 1520 JAF Station New York, NY 10116-1520
emblemhealth.com/medicare
(HIICAP) (New York's SHIP)
(HIICAP) Medicare
1-800-701-0501
TTY
711
New York State Office for the Aging 2 Empire State Plaza Albany, New York 12223-1251
http://www.aging.ny.gov
PRA 1995 OMB OMB 0938-1051CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Microsoft Word 2016