Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage through the CHEIBA Trust and prescription drug coverage available for
people with Medicare. It also explains the options you have under Medicare prescription drug coverage
and 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. At the end
of this notice is information about where you can get help to make decisions about your prescription drug
coverage. Please share this information with any other family member who is covered under the plan and
who may be eligible for Medicare Part D.

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through
Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug
coverage. All Medicare prescription 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. The CHEIBA Trust has determined that the prescription drug coverage offered through the CHEIBA
Trust for the HMO/POS, PRIME PPO and Custom Plus plans is, on average for all plan participants,
expected to pay out as much as the 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 enroll in a
Medicare prescription drug plan.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and
each year from October 15th through December 7th. However, if you lose your current creditable
prescription drug coverage, through no fault of your own, you will be eligible for your two‐month Special
Enrollment Period (SEP) to join a Medicare drug plan.
If you decide to join a Medicare drug plan, your CHEIBA Trust coverage will be affected.

If you do decide to join a Medicare drug plan and drop your CHEIBA Trust prescription drug coverage, be
aware that you and your dependents may not be able to get this coverage back.

You should also know that if you drop or lose your coverage with the CHEIBA Trust 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 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up 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, please reference the
Multi‐Option Plan Summary included in the back pocket of the Benefit Booklet or contact your Human
Resources/Benefits Office for further information. NOTE: You will receive this notice annually and at other
times in the future such as before the next period you can join a Medicare drug plan, and if this coverage
through the CHEIBA Trust 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 prescription drug plans. For more information about Medicare
prescription drug coverage:
 Visit
 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.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is
available. Information about this extra help is available from the Social Security Administration (SSA) on the
web at, or you can call them at 1‐800‐772‐1213 (TTY 1‐800‐325‐0778).

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 required to pay a
higher premium (a penalty).

Name of Entity/Sender:
Colorado School of Mines
Contact--Position/Of ice:
Human Resources/ Benefits Office
1500 Illinois Street

Golden, CO 80401

Phone Number: