Evidence of Coverage - GuideStone Financial ：证据的覆盖guidestone金融

EME19179 CRP 07302013
The Centers for Medicare & Medicaid Services (CMS) requires that Express Scripts Medicare
send you certain plan materials upon your enrollment in a Medicare Part D plan. The enclosed
Evidence of Coverage includes information on standard rules and processes for a Medicare
Part D prescription drug plan program. However, there may be situations where the plan rules
as outlined in the enclosed Evidence of Coverage may differ from your former employer- or
retiree group-provided plan rules and coverage.
Please be sure to review your other plan materials for plan-specific information or contact
Express Scripts Medicare Customer Service.
Evidence of Coverage:
Your Medicare Prescription Drug Coverage as a
Member of Express Scripts Medicare (PDP)
This booklet provides the details about your Medicare prescription drug coverage from
January 1 – December 31, 2014. It explains how to get coverage for the prescription drugs you need.
This is an important legal document. Please keep it in a safe place.
This plan, Express Scripts Medicare
?
(PDP), is offered by Express Scripts Insurance Company or
Medco Containment Life Insurance Company. (When this Evidence of Coverage says “we,” “us” or “our,”
it means Express Scripts Insurance Company or Medco Containment Life Insurance Company. When it says
“plan” or “our plan,” it means Express Scripts Medicare.)
Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.
Express Scripts Medicare Customer Service:
For more help or information, please call Customer Service at the number on the back of your member ID
card (TTY users call: 1.800.716.3231) or go to our plan website at http://wendang.chazidian.com. Calls
to Customer Service are free. Customer Service is available 24 hours a day, 7 days a week. Customer
Service has free language interpreter services available for non-English speakers.
This information is available in braille. Please contact Customer Service at the numbers above if you need
plan information in another format.
This information is available for free in other languages. Please contact Customer Service at the numbers on
the back of your member ID card for additional information. Customer Service is available 24 hours a day,
7 days a week. Esta información está disponible sin cargo en otros idiomas. Comuníquese con el Servicio de
atención al cliente de Express Scripts Medicare llamando a los números que figuran al dorso de su tarjeta de
identificación de miembro para obtener información adicional. El Servicio de atención al cliente está
disponible las 24 horas, los 7 días de la semana.
Benefits, formulary, pharmacy network, premium, deductible and/or copayments/coinsurance may change
on January 1, 2015. E00SOS4A
January 1 – December 31, 2014