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Creditable Coverage Notice

MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011

If you are receiving a copy of this notice electronically, you are responsible for providing a copy of it to any Part-D eligible dependents covered under the group health plan.

Important Notice from The Northern School District Trust About Your Prescription Drug Coverage and Medicare

  • School District of Ashland Empower $3,300 HSA Plan and Empower HSA Plan - $4,000 Ded
  • CESA 12: Empower HSA Plan and Medical Benefit Plan
  • Hurley: Schools Empower HSA Plan
  • Prentice School District Medical Benefit Plan
  • Bayfield School District Medical Benefit Plan
  • Crandon School District Empower HSA Plan and Medical Benefit Plan
  • Solon Springs School District Empower HSA Plan
  • South Shore School District Medical Benefit Plan
  • Winter School District Medical Benefit Plan

Please read this notice carefully and keep it where you can find it. This notice has information about your current
prescription drug coverage with The Northern School District Trust and about your options under Medicare’s prescription drug coverage. This information 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. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this
coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO)
that offers prescription drug coverage. All Medicare 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 Northern School District Trust has determined that the prescription drug coverage offered by the Medical Plan (Plan A or Plan B) for the plan year 2025-26 is, on average for all plan participants, expected to pay out as much as 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 join a Medicare drug plan.

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When Can You Join a Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to
December 7th . However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens to Your Current Coverage If You Decide to Join a Medicare Drug Plan?
If you decide to join a Medicare drug plan, the following options may apply:

  • You may stay enrolled in any of the above medical plans and not enroll in the Medicare prescription drug coverage at this time. You may be able to enroll in the Medicare prescription drug program at a later date without penalty either:
  • During the Medicare prescription drug annual enrollment period, or
  • If you lose your creditable coverage.
  • You may stay enrolled in the Medical Plan and also enroll in a Medicare prescription drug plan. The Medical Plan will be the primary payer for prescription drugs and Medicare Part D will become the secondary payer.
  • You may decline coverage in the Medical Plan and enroll in Medicare as your only payer for all medical and prescription drug expenses. If you do not enroll in the Medical Plan, you are not able to receive coverage through the plan unless and until you are eligible to reenroll in the plan at the next open enrollment period or due to a status change under the cafeteria plan or special enrollment event.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with The Northern School District 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 by 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…
Contact the person listed below for further information.
NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through The Northern School District 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 drug plans.
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).

Date: 10/14/2025
Name/Entity of Sender: The Northern School District Trust
Contact Position/Office: CESA 12 – Joanne Long
Address: 400 Lake Short Drive East, Ashland WI 54806
Phone Number: 715-682-2363