Patient Rights and Information
Medicare Prescription Drug Coverage and Your Rights
YOUR MEDICARE RIGHTS
You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” if you believe:
- you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;”
- a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or
- you need to take a non-preferred drug and you want the plan to cover the drug at the preferred drug price.
WHAT YOU NEED TO DO
You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website. You or your prescriber can request an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:
- The name of the prescription drug that was not filled. Include the dose and strength, if known.
- The name of the pharmacy that attempted to fill your prescription.
- The date you attempted to fill your prescription.
- If you ask for an exception, your prescriber will need to provide your drug plan with a statement explaining why you need the off-formulary or non-preferred drug or why a coverage rule should not apply to you.
Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision.
Refer to your plan materials or call 1-800-Medicare for more information.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0975. The time required to complete this information collection is estimated to average one minute per response, including the time to select the preprinted form, and hand it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850
Form No. CMS-10147 (Approved 09/30/2014) OT962945
Generic Substitution Law
Under Washington law, a less expensive interchangeable biological product or equivalent drug may in some cases be substituted for the drug prescribed by your doctor. Such substitution, however, may only be made with the consent of your doctor. Please consult your pharmacist or physician for more information
Return or Exchange of Drugs Prohibited
Prescriptions, drugs, medicines, sick room supplies and items of personal hygiene shall not be accepted for return or exchange by any pharmacist or pharmacy after such prescriptions, drugs, medicines, sick room supplies or items of personal hygiene have been taken from the premises where sold, distributed or dispensed.
STATE OF WASHINGTON BOARD OF PHARMACY
Olympia, Washington 98504
Notice to our Patients
This pharmacy keeps a record of all prescriptions we provide you. You may ask to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by asking the pharmacist.
Attention Pharmacy Patients
A portion of your prescription may be processed at another Bartell Drugs location unless otherwise requested.
Patient Rights and Responsibilities
- The patient has the right to considerate and respectful service.
- The patient has the right to obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious affiliation.
- Subject to applicable law, the patient has the right to confidentiality of all information pertaining to his/her medical equipment service. Individuals or organizations not involved in the patient’s care, may not have access to the information without the patient’s written consent.
- The patient has the right to make informed decisions about his/her care.
- The patient has the right to reasonable continuity of care and service.
- The patient has the right to voice grievances without fear of termination of service or other reprisal in the service process.
- The patient should promptly notify the Home Medical Equipment Company of any equipment failure or damage.
- The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify Home Medical Equipment Company in such instances.
- The patient should promptly notify the Home Medical Equipment Company of any changes to their address or telephone.
- The patient should promptly notify the Home Medical Equipment Company of any changes concerning their physician.
- The patient should notify the Home Medical Equipment Company of discontinuance of use.
- Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which the patient’s insurance company / companies does not pay.