"The Centers for Medicare & Medicaid Services (CMS) require Cigna-Health Spring Rx to verify and update our records....CMS has provided us with information that you may have other drug coverage or assistance with paying your drugs through the following insurers"

1. Cigna...HealthSpring RxsM
(PDP)
Medicare Part D Prescription Drug Plans
July 30, 2018
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Customer ID:
Dear
Thank you for continuing to be a valuable customer of Cigna-HealthSpring Rx (PDP).
The Centers for Medicare & Medicaid Services (CMS) require Cigna-HealthSpring Rx to verify and update our
records upon your enrollment into our Medicare Prescription Drug Plan, and once a year thereafter, regarding
any other prescr'ption drug coverage you may have. CMS has provided us with information that you may have
other drug coverage or assistance with paying your drugs through the following insurers:
PATIENT ACCESS NETWORK-ADAP
The following form contains tile information CMS provided us regarding your other prescription drug coverage.
If you have any changes to the prescription drug coverage provided, please complete and return the form in
the enclosed business reply envelope or call us at 1-80D-222-67D0. Our customer service representatives are
available 8am - 8pm local time, 7 days a week. Our automated phone system may answer your call during
weekends from Feb. 15 - Sept. 30. TTY users should call 711. Ifthe other prescription drug coverage is
through a State Pharmaceutical Assistance Program (SPAP) and this information in incorrect please also
contact your SPAP so tlley can correct their records.
If the other prescription drug coverage enclosed is correct, you do not need to respond to this
notification.
Thank you,
Cigna-HealthSpring Rx

2. Customer ID:
Reported Coordination of Benefits (COB) from CMS:
COB Field CMS Data Correction if aoolicable
Policy Holder's First Name:
Policy Holder's Last Name:
.
Insurance Name: PATIENT ACCESS NETWORK -ADAP
City:
State:
Zip:
Individual Policy Number: PG592897
Group Policy Number:
Effective Date: 05/20/2015
Termination Date:
Prescription Drug ID:
Prescription Drug Group:
Prescription Drug BIN (located
on ID Card):
006012
Prescription Drug PCN: MEDDPDM
Patient Relationship:
Type of Insurance Coverage: SUPPLEMENTAL
Prescription Drug HEALTH ACCOUNT
Coverage Type:
..Please note the fields marked wffh asterisks "**" above indicate that no information is currently on file.
Please-check the b0x--that properly addresses your change:.
D I have never had prescriptio1 drug coverage through the coverage noted above.
D The coverage noted above became effective or terminated on the date(s) I have written above. Please
cross out the effective andIor termination date(s) provided byMedicare and write the propereffective
andIor termination date(s) above.
D The coverage noted above is incorrect. Please cross out the incorrect data provided by Medicare and
write the properinformation next to each applicable field above.
Signature Date
If you have any other prescription drug coverage, in addition to the above and/ or your Cigna-HealthSpring Rx
plan, please call 1-800-222-6700 to complete a brief coordination of benefits survey. Our customer services
representatives are available 8am - 8pm local time, 7 days a week. Our automated phone system may answer
your call during weekends from Feb. 15 - Sept. 30. TTY users should call 711. If the other prescription drug
coverage provided by Medicare is correct, you do not need to respond to this notification.
501c3
Foundation/Grant

3. Cigna-HealthSpring®
Rx (PDP)
Medicare Part D Prescription Drug Plans
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Notice of Nond;scrimination: Discrimination is Against the Law
Cigna-HealthSpring Rx complies with applicable Federal civil rights laws and does not discriminate on 1he basis of race,
color, national origin, age, disability, or sex. Cigna-HealthSpring Rx does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex.
Cigna-HealthSpring Rx:
• Provides free aids and services to people with disabilrties to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o ·nformation written in other languages
If you need these services, contact Customer Service at 1-800-222-6700 (TTY 711), 8 a.m.-8 p.m. local time, 7 days a
week. Our automated phone system may answer your call during weekends from Feb.15- Sept 30.
If you believe that Cigna-HealthSpring Rx has failed to provide these services or discriminated in another way on the basis
of race, color, national origin, age, disability, or sex, you can file agrievance with:
Cigna-HealthSpring Rx- GrJevance
PO Box 269005
Weston, FL 33326-9927
Phone: 1-800-222-6700 {TTY 711), Fax: 1-800-735-1469
You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service is available to help
you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or
by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The
Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak
languages other than English, language assistance services, free of charge are available to you. Call 1-800-222-6700 (TTY
711), 8 a.m.-8 p.m., 7 days a week. ATENCl6N: si usted hab[a unidioma que no sea ingles, tiene a su disposici6n servicios
gratuitos de asistencia linguistica. Llame al 1-800-222-6700 (TTY 711), 8 a.m.-8 p.m , 7 dias de la semana. Cigna­
HealthSpring Rx (PDP) rs a Medicare Prescription Drug plan (PDP) with a Medicare contract. Enrollment in Cigna-
HealthSpring depends on contract renewal.