Form CMS-10316 Medicare Disenrollee Survey: Prescription Drug Plan

Attachment VII. Stand Alone PDP Survey
Survey Instructions
This survey asks about you and your former prescription drug plan. Answer each
question thinking about yourself. Please take the time to complete this survey. Your
answers are very important to us. Please return the survey with your answers in the
enclosed postage-paid envelope to CSS (the research organization assisting CMS in
conducting this survey).


Answer all the questions by putting an “X” in the box to the left of your answer,
like this:



Yes



Be sure to read all the answer choices given before marking your answer.



Some questions have instructions that tell you to skip questions that may not apply to you.
When this happens you will see an arrow with a note that tells you what question to answer
next, like this: [ If No, go to Question 3].

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 0938-1113 (Expires: TBD). The time required to complete this information
collection is estimated to average 18 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) 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.
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Please read below:

According to CMS records, the following change was made to your Medicare prescription drug
coverage in [MONTH/YEAR]:

 Your former Medicare Prescription Drug Plan was:

[PLAN NAME] [CONTACT #]

 Your new Medicare plan or coverage is:

[PLAN NAME] [CONTRACT #]

 Please answer this survey based only on your experiences with your former plan:

[PLAN MARKETING NAME/CONTRACT #]

 If you were not enrolled in [PLAN NAME/ NUMBER] recently, please answer the survey
based on your experiences with the plan you had before you enrolled in your current plan.

GO TO NEXT PAGE

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ATTENTION: Some questions have instructions that tell you to skip questions that may
not apply to you. Please check for a skip instruction after you answer each question.

YOUR FORMER PRESCRIPTION DRUG PLAN
We are sending you this survey because we believe you recently changed or switched to
another Medicare prescription drug plan or dropped your Medicare prescription drug plan.
1. Our records show that you used to belong to [PLAN_NAME] (Contract Number
[CONTRACTID]) but no longer belong to that plan. Is that right?

 Yes, I changed or switched prescription drug plans  Go to Question 2
 I changed or switched prescription drug plans but my former plan was not
[PLAN_NAME]  Go to Question 2

 No, I did not change, switch, or drop prescription drug plans recently 

Stop. Do not
complete the
rest of this
survey. Please
return the survey
in the enclosed
envelope.

2. Did you have to change, switch, or drop your former prescription drug plan for
any of the following reasons?

 I moved outside of the area where the plan was available
 I was dropped by the plan
 The plan was cancelled or discontinued in my area
 The plan was changed or discontinued by the organization

}

that provides my insurance (such as a former employer or
a union)

Stop. Do not
complete the rest of
this survey. Please
return the survey in
the enclosed
envelope.

 None of the above  Continue survey, go to Question 3

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GETTING INFORMATION OR HELP
FROM YOUR FORMER
PRESCRIPTION DRUG PLAN
As you answer the questions in this
survey, please think only of your former
prescription drug plan.
3. Did you ever try to get information or
help from your former plan’s
customer service?

 Yes
 No  If No, go to Question 5
4. How often did your former plan’s
customer service give you the
information or help you needed?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information or help
from my former plan’s customer
service
5. Did you ever try to get information
from your former plan about which
prescription medicines were
covered?

 Yes
 No  If No, go to Question 7

6. How often did your former plan give
you all the information you needed
about which prescription medicines
were covered?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information from my
former plan about which prescription
medicines were covered
7. Did you ever try to get information
from your former plan about how
much you would have to pay for a
prescription medicine?

 Yes
 No  If No, go to Question 9
8. How often did your former plan give
you information about how much you
would have to pay for a prescription
medicine?

 Never
 Sometimes
 Usually
 Always
 I did not try to get information from my
former plan about how much I would
have to pay for a prescription medicine

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GETTING THE PRESCRIPTION
MEDICINES YOU NEEDED FROM
YOUR FORMER PRESCRIPTION
DRUG PLAN

9. Did a doctor ever prescribe a
medicine for you that your former
plan did not cover?

 Yes
 No
10. How often was it easy to use your
former plan to get the medicines
your doctor prescribed?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to get
any prescription medicines
11. Did you ever use your former plan to
fill a prescription at a pharmacy?

 Yes
 No If No, go to Question 13
12. How often was it easy to use your
former plan to fill a prescription
at a pharmacy?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to fill a

13. Did you ever use your former plan to fill
any prescriptions by mail?

 Yes
 No  If No, go to Question 15
14. How often was it easy to use your
former plan to fill prescriptions by
mail?

 Never
 Sometimes
 Usually
 Always
 I did not use my former plan to fill a
prescription by mail
15. Using any number from 0 to 10, where
0 is the worst prescription drug plan
possible and 10 is the best
prescription drug plan possible, what
number would you use to rate your
former plan?

 0 Worst prescription drug plan possible
1
2
3
4
5
6
7
8
9
 10 Best prescription drug plan possible

prescription at a pharmacy

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REASONS YOU LEFT YOUR FORMER
PRESCRIPTION DRUG PLAN
The next questions are about reasons you
may have had for changing, switching or
dropping your former prescription drug plan.

16. Did you leave your former plan
because you found out that
someone had signed you up for
the plan without your permission?

 Yes
 No
17. Did you leave your former plan
because you were taken off the plan
by mistake?

 Yes
 No
18. Did you leave your former plan
because the dollar amount you had
to pay each time you filled or refilled
a prescription went up?

 Yes
 No
 I did not have to pay for my
prescription medicines
19. Some people have to pay their
prescription drug plan a monthly fee
(called a premium) out of their own
pocket for prescription drug
coverage.
Did you leave your former plan
because this monthly fee went up?

20. Prescription drug plans have a list of
the prescription medicines they will
cover. Did you leave your former plan
because they changed the list of
prescription medicines they cover?

 Yes
 No
21. Did you leave your former plan
because you found a prescription
drug plan that costs less?

 Yes
 No
22. Did you leave your former plan
because a change in your personal
finances meant you could no longer
afford the plan?

 Yes
 No
23. Did you leave your former plan
because the plan refused to pay
for a medicine your doctor
prescribed?

 Yes
 No
24. Did you leave your former plan
because you had problems getting
the medicines your doctor
prescribed?

 Yes
 No

 Yes
 No
 I did not have to pay my former plan a
monthly fee out of my own pocket
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25. Did you leave your former plan
because it was difficult to get brand
name medicines?

 Yes
 No
 I did not try to get brand name
medicines through my former plan
26. Did you leave your former plan
because you were frustrated by the
plan’s approval process for medicines
your doctor prescribed?

 Yes
 No
27. Did you leave your former plan
because you did not know whom to
contact when you had a problem
filling or refilling a prescription?

 Yes
 No
28. Did you leave your former plan
because it was hard to get
information from the plan—like which
prescription medicines were covered
or how much a specific medicine
would cost?

 Yes
 No
29. Did you leave your former plan
because you were unhappy with how
the plan handled a question or
complaint?

 Yes
 No

30. Did you leave your former plan
because you could not get the
information or help you needed from
the plan?

 Yes
 No
31. Did you leave your former plan
because their customer service staff
did not treat you with courtesy and
respect?

 Yes
 No
32. Every year Medicare evaluates all
prescription drug plans and gives
them a star rating that gives
information on prescription drug
plan quality.
Have you ever seen the Medicare Star
Rating for any health plan?

 Yes
 No If No, go to Question 36
33. Did you leave your former plan because
it got a low star rating?

 Yes
 No
34. Did you leave your former plan
because you found another plan with
a higher star rating?

 Yes
 No

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35. In the past year, did you consider
the Medicare Star Ratings when
trying to choose a plan?

 Yes
 No
OTHER REASONS FOR
LEAVING YOUR FORMER
PRESCRIPTION DRUG PLAN
36. Did you leave your former plan
because a family member or friend
told you about a better plan?

 Yes
 No
37. Did you leave your former plan
because you saw a commercial or
advertisement for a prescription drug
plan you thought you would like
better?

 Yes
 No
38. Did you leave your former plan
because you found another plan
that better met your prescription
needs?

 Yes
 No
39. Did you leave your former plan
because you take very few
prescription medicines and don’t
need a prescription drug plan?

 Yes
 No

ABOUT YOU
40. In general, how would you rate your
overall health?

 Excellent
 Very good
 Good
 Fair
 Poor
41. In general, how would you rate your
overall mental or emotional health?

 Excellent
 Very good
 Good
 Fair
 Poor
42. In the past 12 months, how many
different prescription medicines did
you take?

 None
 1 to 2 medicines
 3 to 5 medicines
 6 or more medicines
43. In the past 12 months, have you seen a
doctor or other health provider 3 or
more times for the same condition or
problem?

 Yes
 No  If No, go to Question 45

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44. Is this a condition or problem that
has lasted for at least 3 months?
 Yes

 No

 Yes
 No  If No, go to Question 47
46. Is this medicine to treat a condition
that has lasted for at least 3
months?

 Yes
 No
47. Has a doctor ever told you that you
had any of the following conditions?
a. A heart attack
b. Angina or coronary
heart disease
c. High blood pressure
or hypertension
d. Cancer, other than
skin cancer
e. Emphysema, asthma
or COPD (chronic
obstructive pulmonary
disease)
f. Any kind of diabetes
or high blood sugar




 8th grade or less
 Some high school, but did not
graduate

45. Do you now need or take any
medicine prescribed by a doctor
for any condition?

Yes

48. What is the highest grade or level of
school that you have completed?

No




















 High school graduate or GED
 Some college or 2-year degree
 4-year college graduate
 More than 4-year college degree
49. Are you of Hispanic or Latino origin or
descent?

 Yes, Hispanic or Latino
 No, not Hispanic or Latino
50. What is your race? Please mark one
or more.

 White
 Black or African-American
 Asian
 Native Hawaiian or other Pacific
Islander

 American Indian or Alaska Native

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51. What language do you mainly speak
at home?

 Chinese
 English
 Russian
 Spanish
 Vietnamese
 Some other language (please print)

52. Did someone help you complete
this survey?

 Yes
 No  If No, go to Question 54

53. How did that person help you? Please
mark one or more.

 Read the questions to me
 Wrote down the answers I gave
 Answered the questions for me
 Translated the questions into my


language
Helped in some other way (please
print)

54. May we contact you again if we have
questions about your survey
responses or if we have other
questions about the health care
services that you received?

 Yes
 No

THANK YOU FOR COMPLETING THIS
SURVEY
Please return your completed survey in the postage paid envelope to:
MEDICARE SATISFACTION
SURVEY
PO BOX 1920
MANCHESTER, CT 06045-9939

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