Discrimination is Against the Law
Westbury Senior Care Pharmacy complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Westbury Senior Care Pharmacy does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Westbury Senior Care Pharmacy:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact Tonya Westbury.
If you believe that Westbury Senior Care Pharmacy 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 a grievance with Tonya Westbury, 1012 Memorial Drive, Suite 15, Griffin, GA 30223, 770-233-8999 (phone), 770-233-8976 (fax), email@example.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Tonya Westbury 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.
MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS (APPROVED OMB #0938-0975)
You have the right to get a written explanation from your Medicare drug plan if:
- Your doctor or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed by your doctor.
- You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.
The Medicare drug plan’s written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.
You also have the right to ask your Medicare drug plan for 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;” or
- You believe you should get a drug you need at a lower cost-sharing amount.
What you need to do:
- Contact your Medicare drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary or believe you should get a drug you need at a lower cost-sharing amount.
- Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan.
- When you contact your Medicare drug plan, be ready to tell them:
- The prescription drug(s) that you believe you need.
- The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.
- The date you were told that the prescription drug(s) is not covered.
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 distribute this information collection once it has been completed is 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, Baltimore, Maryland 21244-1850. No. CMS-10147