Page 27 - RS&A Benefits Enrollments Guide

For more information about Medicare prescription drug coverage:
• Visit www. Medicare.gov
• 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.

If you have limited income and resources, extra help paying for Medicare prescription drug
coverage is available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or 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 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).

For purposes of this notice, the plan administrator is:

Date: April 1, 2018

Name of Entity/Sender: RS&A, Inc.

Contact: Jill Drennan, VP of Human Resources

Address: 465 Forum Parkway Rural Hall, NC 27045

Phone Number: 336.969.7057

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 0938-0990. The time required to complete
this information collection is estimated to average 8 hours per response initially, 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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