2024-2025 Creditable Coverage Disclosure Notice

Exactly as extracted, unformatted — for checking against the original. The readable version is easier to read.

THE TOWN OF CENTREVILLE 101 LAWYERS ROW CENTREVILLE, MD 21617
410-758-1180 FAX 410-758-4741 WWW.TOWNOFCENTREVILLE.ORG
Creditable Coverage Disclosure Notice
Important Notice from Town of Centreville about Your Prescription Drug
Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage with Town of Centreville and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not you want to join a Medicare
drug plan. If you are considering joining, you should compare your current coverage, including which drugs
are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug
coverage in your area. Information about where you can get help to make decisions about your prescription
drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription
drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You
can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage
Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide
at least a standard level of coverage set by Medicare. Some plans may also offer more coverage
for a higher monthly premium.
2. Town of Centreville has determined that the prescription drug coverage offered by Cigna Gold or
Silver Plan is, on average for all plan participants, expected to pay out as much as standard
Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.
Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a
higher premium (a penalty) if you later decide to join a Medicare drug plan.
______________________________________________________________________________________
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October
15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will
also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide To Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Town of Centreville coverage will not be affected.
Gold Plan
The prescription drug coverage that is offered through Town of Centreville has an annual deductible, employer
contribution of $1,300 for individual and $2,600 for family. Participants are responsible for co-payments that

vary by the drug type and whether the prescription is filled at a retail pharmacy or through mail order. For
prescriptions obtained at a participating retail pharmacy (up to a 30-day supply) the co-payments are: $10 for
Generic Drugs, $40 for Brand-Name Formulary Drugs, and $75 for Brand-Name Non-Formulary Drugs. For
prescriptions obtained at a participating retail pharmacy ( up to a 90 day supply) the co-payments are: $25 for
Generic Drugs, $100 for Brand-Name Formulary Druds, and $188 for Non-preferred brand Drugs. For prescriptions
obtained through mail order (up to a 90 day supply) the co-payments are: $25 for Generic Drugs, $100 for
Brand-Name Formulary Drugs, and $188 for Brand-Name Non-Formulary Drugs.
Silver Plan
The prescription drug coverage that is offered through Town of Centreville has an annual deductible, employer
contribution of $2,000 for individual and $4,000 for family. Participants are responsible for co-payments that
vary by the drug type and whether the prescription is filled at a retail pharmacy or through mail order. For
prescriptions obtained at a participating retail pharmacy (up to a 30 day supply) the co-payments are: $10 for
Generic Drugs, $40 for Brand-Name Formulary Drugs, and $75 for Brand-Name Non-Formulary Drugs. For
prescriptions obtained at a participating retail pharmacy ( up to a 90 day supply) the co-payments are: $25 for
Generic Drugs, $100 for Brand-Name Formulary Druds, and $188 for Non-preferred brand Drugs. For prescriptions
obtained through mail order (up to a 90 day supply) the co-payments are: $25 for Generic Drugs, $100 for
Brand-Name Formulary Drugs, and $188 for Brand-Name Non-Formulary Drugs.
If you do decide to join a Medicare drug plan and drop your current Town of Centreville Gold or Silver Cigna
Plan coverage, be aware that you and your dependents will be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Town of Centreville and don’t join a
Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 days or longer without creditable prescription drug coverage, your monthly premium may go up
by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have
that coverage. For example, if you go nineteen months without creditable coverage, your premium may
consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this
higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may
have to wait until the following October to join.
For More Information about This Notice or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also
get it before the next period you can join a Medicare drug plan, and if this coverage through Town of
Centreville changes. You also may request a copy of this notice at any time.
For More Information about Your Options under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be
contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help.
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is
available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or
call them at 1-800-772-1213 (TTY 1-800-325-0778).
For use on or after 04/1/11 Rev. 10/05/2023

Remember: Keep this Creditable Coverage notice. If you decide to join one of the
Medicare drug plans, you may be required to provide a copy of this notice when you join to
show whether or not you have maintained creditable coverage and, therefore, whether or
not you are not required to pay a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office: Krystel Ebaugh-
Address: 101 Lawyers Row Centreville, MD 21617
Phone Number: 410-758-1180
For use on or after 04/1/11 Rev. 10/05/2023
Human Resources Manager/Town Hall
06/11/2024
Town of Centreville