Disclaimers

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for
getting extra help, call:

• 1-800-MEDICARE (1-800-663-4227). TTY or TDD users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY or TDD users should call 1-800-352-0778; or
• Your State Medical Assistance (Medicaid) Office.

Retail, mail order, LTC, I/T/U and home infusion pharmacies are included in the plan network. For more information on mail order prescription drug service call 1-800-731-0459, 8 a.m. - 8 p.m., 7 days a week, TTY/TDD users should call 1-888-877-2837.

You are eligible to enroll in this plan if you are entitled to Medicare benefits under Part A and/or enrolled in Part B and reside in Wisconsin. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.

For general information about Medicare Prescription Drug Coverage call 1-800-MEDICARE 1-800-633-4227, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Wisconsin Physicians Service Insurance Corporation (WPS Health Insurance) is authorized by law to refuse to renew its contract with the Centers for Medicare and Medicaid Services (CMS). CMS also may refuse to renew the contract. Termination or non-renewal of this contract may result in termination of the beneficiary’s enrollment in the WPS MedicareRx Plan. In addition, the WPS MedicareRx Plan may reduce its service area and no longer offer services in the area where you reside.

Wisconsin Physicians Service Insurance Corporation (WPS Health Insurance) is a Medicare approved Part D sponsor.

Members may enroll in a plan only during specific times of the year. To obtain more information about these dates please call 1-800-731-0459, 1-888-877-2837 TTY/TDD, 8 a.m. - 8 p.m., 7 days a week.

Benefits, formulary, pharmacy network, premium, copayments and/or coinsurance may change on January 1, 2011. Please contact Wisconsin Physicians Service Insurance Corporation for details.

This document is available in alternative formats.

Medicare beneficiaries may enroll in the WPS MedicareRx Plan through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov. For more information contact the WPS MedicareRx Plan at 1-800-731-0459, 1-888-877-2837 TTY/TDD, 8 a.m. - 8 p.m., 7 days a week.

Medicare beneficiaries enrolled in an MA PFFS plan that includes Medicare prescription drugs or any MA coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or MA PFFS plan if they enroll in a PDP.

Medicare beneficiaries enrolled in a private fee-for-service plan (PFFS) that does not include Medicare prescription drug coverage, an MA Medical Savings Account (MSA) plan or an 1876 Cost plan may enroll in a PDP and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost plan.

If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will be responsible for the timely payment of all premiums during that time.

For full information on WPS MedicareRx Plan benefits, call our Customer Service Department at 1-800-731-0459, 1-888-877-2837 TTY/TDD, 8 a.m. - 8 p.m., 7 days a week.