Medicare Advantage and Medicare Fee-For-Service CAHPS Survey: Stand Alone PDP Survey (CMS-R-246)

2011 PDP Survey (April)	2011 PDP Survey Revised
1. Our records show that in 2010 your Medicare prescription drugs were covered by the plan named on the back cover. Is that right?  Yes If Yes, Go to Question 3  No	1. Our records show that in 2010 your Medicare prescription drug were covered by the plan named on the back cover. Is that right?  Yes If Yes, Go to Question 3  No
2. Please write below the name of the Medicare prescription drug plan you had in 2010 and complete the rest of the survey based on the experiences you had with that plan. (Please print)	2. Please write below the name of the Medicare prescription drug plan you had in 2010 and complete the rest of the survey based on the experiences you had with that plan. (Please print)
3. Customer service is information you get from staff about what is covered and how to use the plan. In the last 6 months, did you try to get information or help from your prescription drug plan’s customer service about prescription drugs?  Yes  No If No, Go to Question 5	3. Customer service is information you get from staff about what is covered and how to use the plan. In the last 6 months, did you try to get information or help from your prescription drug plan’s customer service about prescription drugs?  Yes  No If No, Go to Question 5
5. In the last 6 months, how often did your prescription drug plan’s customer service give you the information or help you needed about prescription drugs?  Never  Sometimes  Usually  Always	5. In the last 6 months, how often did your prescription drug plan’s customer service give you the information or help you needed about prescription drugs?  Never  Sometimes  Usually  Always
6. In the last 6 months, how often did your prescription drug plan’s customer service treat you with courtesy and respect when you tried to get information or help about prescription drugs?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.	6. In the last 6 months, how often did your prescription drug plan’s customer service treat you with courtesy and respect when you tried to get information or help about prescription drugs?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.
7. In the last 6 months, did you try to get information from your prescription drug plan about which prescription medicines were covered?  Yes  No →If No, Go to Question 9	7. In the last 6 months, did you try to get information from your prescription drug plan about which prescription medicines were covered?  Yes  No →If No, Go to Question 9
8. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about which prescription medicines were covered?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months	8. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about which prescription medicines were covered?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.
9. In the last 6 months, did you try to get information from your prescription drug plan about how much you would have to pay for your prescription medicines?  Yes  No →If No, Go to Question 11	9. In the last 6 months, did you try to get information from your prescription drug plan about how much you would have to pay for your prescription medicines?  Yes  No →If No, Go to Question 11
10. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about how much you would have to pay for your prescription medicine?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.	10. In the last 6 months, how often did your prescription drug plan’s customer service give you all the information you needed about how much you would have to pay for your prescription medicine?  Never  Sometimes  Usually  Always  I did not try to get information or help from my prescription drug plan’s customer service in the last 6 months.
11. In the last 6 months, how many different prescription medicines did you fill or have refilled?  None  1 to 2 medicines  3 to 5 medicines  6 or more medicines	11. In the last 6 months, how many different prescription medicines did you fill or have refilled?  None  1 to 2 medicines  3 to 5 medicines  6 or more medicines
12. In the last 6 months, did a doctor prescribe a medicine for you that your prescription drug plan did not cover?  Yes  No →If No, Go to Question 16	12. In the last 6 months, did a doctor prescribe a medicine for you that your prescription drug plan did not cover?  Yes  No →If No, Go to Question 16
13. When this happened, did you contact your prescription drug plan to ask them to cover the medicine your doctor prescribed?  Yes  No →If No, Go to Question 16  All my prescribed medicines were covered.	13. When this happened, did you contact your prescription drug plan to ask them to cover the medicine your doctor prescribed?  Yes  No →If No, Go to Question 16  All my prescribed medicines were covered.
14. When you contacted your prescription drug plan about the decision not to cover a prescription medicine did they … Please mark one or more.  Tell you that you can file an appeal  Offer to send you forms that you need to file an appeal  Suggest how to resolve your complaint  Listen to your complaint but did not help to resolve it  Discourage you from taking action  Do none of the above  All my prescribed medicines were covered	14. When you contacted your prescription drug plan about the decision not to cover a prescription medicine did they … Please mark one or more.  Tell you that you can file an appeal  Offer to send you forms that you need to file an appeal  Suggest how to resolve your complaint  Listen to your complaint but did not help to resolve it  Discourage you from taking action  Do none of the above  All my prescribed medicines were covered
15. In the last 6 months, how often was it easy to use you prescription drug plan to get the medicines your doctor prescribed?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to get any medicines in the last 6 months.	15. In the last 6 months, how often was it easy to use you prescription drug plan to get the medicines your doctor prescribed?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to get any medicines in the last 6 months.
16. In the last 6 months, did you ever use you prescription drug plan to fill a prescription at your local pharmacy?  Yes  No →If No, Go to Question 18	16. In the last 6 months, did you ever use you prescription drug plan to fill a prescription at your local pharmacy?  Yes  No →If No, Go to Question 18
17. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription at your local pharmacy?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.	17. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription at your local pharmacy?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.
18. In the last 6 months, did you ever use you prescription drug plan to fill any prescription by mail?  Yes  No →If No, Go to Question 20	18. In the last 6 months, did you ever use you prescription drug plan to fill any prescription by mail?  Yes  No →If No, Go to Question 20  I am not sure if my drug plan offers prescriptions by mail.
19. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription by mail?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.	19. In the last 6 months, how often was it easy to use you prescription drug plan to fill a prescription by mail?  Never  Sometimes  Usually  Always  I did not use my prescription drug plan to fill a prescription at my local pharmacy in the last 6 months.  I am not sure if my drug plan offers prescriptions by mail.
20. 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 prescription drug plan?  0 Worst health plan possible  1  2  3  4  5  6  7  8  9  10 Best health plan possible	20. 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 prescription drug plan?  0 Worst health plan possible  1  2  3  4  5  6  7  8  9  10 Best health plan possible
21. Would you recommend your prescription drug plan for coverage of prescription drugs to other people like yourself?  Definitely yes  Somewhat yes  Somewhat no  Definitely no	21. Would you recommend your prescription drug plan for coverage of prescription drugs to other people like yourself?  Definitely yes  Somewhat yes  Somewhat no  Definitely no
About You	About You
22. In general, how would you rate your overall health?  Excellent  Very good  Good  Fair  Poor	22. In general, how would you rate your overall health?  Excellent  Very good  Good  Fair  Poor
23. In general, how would you rate your overall mental health?  Excellent  Very good  Good  Fair  Poor	23. In general, how would you rate your overall mental health?  Excellent  Very good  Good  Fair  Poor
24. 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 26	24. 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 26
25. Is this a condition or problem that has lasted for at least 3 months?  Yes  No	25. Is this a condition or problem that has lasted for at least 3 months?  Yes  No
26. Do you now need or take medicine prescribed by a doctor?  Yes  No → If No, Go to Question 51	26. Do you now need or take medicine prescribed by a doctor?  Yes  No → If No, Go to Question 70
27. Is this to treat a condition that has lasted for at least 3 months?  Yes  No	27. Is this to treat a condition that has lasted for at least 3 months?  Yes  No
28. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it?  Yes  No  My doctor did not prescribe any medicines for me in the last 6 months	28. In the last 6 months, did you delay or not fill a prescription because you felt you could not afford it?  Yes  No  My doctor did not prescribe any medicines for me in the last 6 months
29. 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. A stroke? d. Cancer, other than skin cancer? e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? f. Any kind of diabetes or high blood sugar?	29. 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. A stroke? d. Cancer, other than skin cancer? e. Emphysema, asthma or COPD (chronic obstructive pulmonary disease)? f. Any kind of diabetes or high blood sugar?
30. Did you get a flu shot since September 1, 2010?  Yes  No  Don’t know	30. Have you had a flu shot since September 1, 2010?  Yes  No  Don’t know
31. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.  Yes  No  Don’t know	31. Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.  Yes  No  Don’t know
32. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?  Every day  Some days  Not at all →If No, Go to Question 34  Don’t know → If Don’t know, Go to Question 34	32. Do you now smoke cigarettes or use tobacco every day, some days, or not at all?  Every day  Some days  Not at all →If No, Go to Question 34  Don’t know → If Don’t know, Go to Question 34
33. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider?  Never  Sometimes  Usually  Always  I had no visits in the last 6 months.	33. In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider?  Never  Sometimes  Usually  Always  I had no visits in the last 6 months.
34. What is your age?  18 to 24  25 to 34  35 to 44  45 to 54  55 to 64  65 to 69  70 to 74  75 to 79  80 to 84  85 or older	34. What is your age?  18 to 24  25 to 34  35 to 44  45 to 54  55 to 64  65 to 69  70 to 74  75 to 79  80 to 84  85 or older
35. Are you male or female?  Male  Female	35. Are you male or female?  Male  Female
36. What is the highest grade or level of school that you have completed?  8th grade or less  Some high school, but did not graduate  High school graduate or GED  Some college or 2-year degree  4-year college graduate  More than 4-year college degree	36. What is the highest grade or level of school that you have completed?  8th grade or less  Some high school, but did not graduate  High school graduate or GED  Some college or 2-year degree  4-year college graduate  More than 4-year college degree
37. Are you of Hispanic or Latino origin or descent?  Yes, Hispanic or Latino  No, not Hispanic or Latino	37. Are you of Hispanic or Latino origin or descent?  Yes, Hispanic or Latino  No, not Hispanic or Latino
38. 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	38. 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
39. Did someone help you complete this survey?  Yes  No → If No, Go to Question 41	39. Did someone help you complete this survey?  Yes  No → If No, Go to Question 41
40. 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	40. 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
41. Do you live alone?  Yes, I live alone  No, I live with others	41. Do you live alone?  Yes, I live alone  No, I live with others
22. The Medicare Program is trying to learn more about the health care or services provided to people with Medicare. May we contact you again about the health care services that you received?  Yes  No	42. The Medicare Program is trying to learn more about the health care or services provided to people with Medicare. May we contact you again about the health care services that you received?  Yes  No

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