If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get Extra Help. This does not include any Medicare Part B premium you may have to pay.

For, Region

Your Level of Extra Help	SmartD Rx Saver	SmartD Rx Plus
100%	$	$
75%	$	$
50%	$	$
25%	$	$

If you aren't getting extra help, you can see if you qualify by calling:

• 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call Member Services at 1-888-328-0420 (TTY: 1-888-328-0419) 24 hours a day, 7 days a week.

Additional Plan Information

Summary of Benefits - this document provides you with details about the SmartD Rx plan and what it covers.

Evidence of Coverage - this document tells you everything you need to know about the SmartD Rx prescription benefit plan, how it works, how to use it and what is covered.

Out of Network Coverage Rules
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. SmartD Rx will cover prescriptions filled at out-of-network pharmacies only in the case of an emergency.

In these situations, please check first with Member Services to see if there is a network pharmacy nearby. You can call 24 hours a day, 7 days a week at 1-888-328-0420 (TTY: 1-888-328-0419)

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. Be sure to keep you receipts reimbursement may be available call Member Services for more information.

Transition Policy
There are times when you may be eligible for a temporary supply or a transitional supply of medication to help make changing your prescription drugs a little easier and to make sure you have the medications you need. These situations include times when a medication you are taking is no longer on our formulary or drug list or a medication you are taking now requires Prior Authorization or Step Therapy.

To ask for a temporary supply, contact Member Services 1-888-328-0420 (TTY: 1-888-328-0419).

A transition supply is provided to give you one fill of your prescription within the first 90 days of a new plan and allow you time to work with your prescriber and decide together what the best course of treatment is for you. You should take into consideration the formulary as well as the amount each medication may cost you.

Dis-Enroll Rights and Responsibilities
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period which takes place from October 15 to December 7.

Members of SmartD Rx may be eligible to end their membership at other times of the year, depending upon the situation. If any of the following situations apply to you, you are eligible to end your membership during a Special Enrollment Period. These are just examples:

• If you have moved out of your plan's service area.
• If you have Medicaid.
• If you are eligible for Extra Help for your Medicare prescriptions.
• If we violate our contract with you.
• If you are getting care in an institution, such as a nursing home or long-term care facility.

If you chose to change to another plan you do not need to dis-enroll from SmartD Rx. Medicare will notify us that you have enrolled in a different plan. You should continue to use your SmartD Rx benefit at a participating network pharmacy to fill your prescriptions until your dis-enrollment date.

If you still want to disenroll from SmartD Rx, please contact Member Services at 1-888-328-0420.

For more information regarding the Low Income Subsidy amounts, click here.

Best Available Evidence

Click here to view the SmartD Rx Best Available Evidence Policy.

Click here to access the CMS Best Available Evidence Policy and to find out how you may become eligible for Extra Help or the Low Income Subsidy. You will be leaving the SmartD Rx website.

As part of our ongoing efforts to contain the rising costs associated with healthcare services and medications, we are committed to detecting, preventing, correcting and deterring acts or attempted acts of fraud, waste and abuse. Fraud, waste, and abuse result in resources being diverted for illegitimate purposes and results in increases of healthcare costs to those who are in truly in need. We are dedicated to providing information to our enrollees and providers about how to identify and report activities involving fraud, waste, and abuse.

What is Fraud, Waste, and Abuse?

Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Waste - To use health care benefits or spend health care dollars without finding a real need for the services or assets. For example, a doctor prescribing a medication for 30 days with a refill when it is not known if the medication will be needed beyond the initial period it was prescribed.

Abuse - Provider practices that are not consistent with sound fiscal, business or medical practices that result in unnecessary costs to the health care system, such as providing a prescription to a beneficiary that is not warranted by a medical diagnosis or condition

How to Report Fraud, Waste, and Abuse

If you suspect fraud, waste, and abuse, you can contact us in one of these ways:

Phone: 1-888-328-0420
Email: PartDFraud@SmartDRx.com
Mail: SmartD Rx
ATTN: FWA Unit
P.O Box 1417
Mechanicsburg, PA 17055

Medicare: 1-800-MEDICARE (1-800-633-4227)

You can choose to report incidents of fraud, waste and abuse anonymously. Any information that is provided to us will be treated confidentially. We reveal the results of our investigations only to those authorities or individuals who have a legitimate reason to receive it (for example, federal and state law enforcement authorities, medical director, senior managers and legal department).

How We Investigate Allegation of Fraud, Waste, and Abuse

Identifying Fraud, Waste and Abuse

State Health Insurance Assistance Programs
To get free help from an independent organization that is not connected with our plan, click herefor a list of State Health Insurance Assistance Programs you can contact in your state.

State Pharmaceutical Assistance Programs Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules to provide drug coverage to its members. Click here for a list of State Pharmaceutical Assistance Programs.

Quality Improvement Organizations
When your complaint is about quality of care, you may make your complaint to the Quality Improvement Organization. Click here for a list of Quality Improvement Organizations.

Medicaid
Medicaid is a joint Federal and State government program that helps with medical costs for certain people with limited incomes and resources. Click here for a list of state-specific Medicaid agencies.

State Health Departments
If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with your State Department of Health. Click here for a list of State Health Departments.

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