Texas Rx Disenrollment Information

Voluntary Disenrollment

You may disenroll from Texas Rx during:

• The annual enrollment period.
  • The annual enrollment period is November 15th through December 31st of each year.
• A special enrollment period which includes situations where:
  • You have made a change in residence outside the service area or have experienced another change in circumstances as determined by the Centers for Medicare & Medicaid Services (CMS) that causes you to no longer be enrolled in Texas Rx.
  • You are entitled to Medicare Part A and Part B and you receive any type of assistance from the Title XIX (Medicaid) program.
  • CMS or the organization has terminated Texas Rx's contract in the area in which you reside, or the organization has notified you of the impending termination of Texas Rx or the impending discontinuation of Texas Rx in the area in which you reside.
  • You demonstrate that Texas Rx substantially violated a material provision of its contract with CMS in relation to you, or Texas Rx (or its agent) materially misrepresented Texas Rx when marketing Texas Rx.
  • You involuntarily lose creditable coverage, including a reduction in the level of coverage so that it is no longer creditable, not including any such loss or reduction due to your failure to pay premiums.
  • You were not adequately informed of the creditable status of drug coverage provided by an entity required to give such notice, or a loss of creditable coverage.
  • Your enrollment or non-enrollment in Texas Rx is erroneous due to an action, inaction or error by a Federal Employee.
  • You meet such other exceptional conditions as CMS may provide.

During a special enrollment period, you may discontinue enrollment in a Prescription Drug Plan (PDP) offered by a PDP sponsor or change to a different Part D plan. If you disenroll from or are disenrolled from Texas Rx, you may subsequently enroll in a new Part D plan within the special enrollment period time period. Once you have enrolled in a new Part D plan, the special enrollment period ends for you even if the time frame for the special enrollment period is still in effect. You may disenroll by:

1. Mailing or faxing a signed written notice to Scott & White Health Plan.
2. Calling 1-800-MEDICARE.

Involuntary Disenrollment

Texas Rx may disenroll you if:

• Premiums are not paid on a timely basis.
• You engage in disruptive behavior.
• You provide fraudulent information on an enrollment request, or if you permit abuse of an enrollment card in Texas Rx.

In situations where Texas Rx disenrolls you involuntarily for any of the reasons addressed above, Texas Rx must send notice of the upcoming disenrollment that:

• Advises you Texas Rx is planning to disenroll you and why such action is occurring,
• Provides the effective date of termination, and
• Includes an explanation of your right to a hearing under Texas Rx's grievance procedures.

Required Involuntary Disenrollment

Texas Rx must disenroll you in the following cases:

• A permanent change in residence making you ineligible to be an enrollee of Texas Rx.
• You lose entitlement to Medicare.
• You die.
• The Texas Rx contract is terminated, or Texas Rx discontinues offering a Prescription Drug Plan in the area where Texas Rx had previously been available. Note: Texas Rx is authorized by law to refuse to renew its contract with CMS. In addition, CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment in Texas Rx.
• You materially misrepresent information to Texas Rx regarding reimbursement for third-party coverage.

Please refer to Evidence of Coverage for Full Disclosure.

The above information is current as of November 2007.

Texas Rx is offered by Scott & White Health Plan, a Medicare Prescription Drug Plan that contracts with Medicare.

S5915_WEBD_DISENROLL_2008

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