2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

PharmacyMaximum Dosing Quantity for 30-day SupplyUnder this pharmacy benefit enhancement, amember’s 30-day prescription supply will be filled,up to the maximum dosing recommended by themanufacturer, without charging any additional copayments.The prescription will still be subject toone of the three (preferred generic, preferredbrand, non-preferred) applicable co-payments.Medicare Prescription Drug BenefitThe Medicare Modernization Act of 2003established the new voluntary outpatientprescription drug benefit program (Medicare PartD). The Medicare Part D prescription drug benefitbecame available to beneficiaries beginning onJanuary 1, 2006. The Medicare Part D prescriptiondrug benefit will allow all Medicare beneficiaries toenroll in drug coverage through a prescription drugplan or Medicare Advantage Plan, with Medicarepaying approximately 75 percent of the premium onaverage (more for qualifying, low-incomebeneficiaries). The Medicare Part D drug benefitincludes beneficiary protections intended to ensurethat all beneficiaries have coverage for medicallynecessary drugs through nearby pharmacies. Drugplans are subject to many of the existingbeneficiary protections that are available inMedicare, including requirements to meet strictpharmacy access standards to give beneficiariesaccess to retail pharmacies and needed drugs.In 2006, Presbyterian launched prescription drugplans for our Medicare-eligible beneficiaries. Theseplans are also known as Medicare Part D. Thisprescription drug coverage is available to anyindividual who is Medicare-eligible. Some of theemployer group plans also have Medicare Part Dcoverage already built in. Presbyterian offers bothHealth Maintenance Organization (HMO) andPreferred Provider Organization (PPO) plans withprescription drug coverage.Please verify the information on the member’sidentification card at the time of service. If themember’s coverage and plan includes prescriptiondrug coverage, it will be noted on the member’s IDcard.Medicare Stages of CoverageMedicare plans consist of the following stages ofcoverage:Annual deductible: The amount thebeneficiary will pay out of pocket for theirprescriptions each year before the initialcoverage begins. There are currently nodeductibles for Presbyterian’s MedicareAdvantage plans.Initial Coverage: Initial coverage begins whenthe first prescription (in the contract year) isfilled. Presbyterian covers the cost of themedications after the member has met theirco-payment requirement.Coverage gap (donut hole): After the benefitspaid out by both Presbyterian and the memberreaches a yearly specified amount, themember is fully responsible for a portion of thecosts (dependent on the Centers for Medicareand Medicaid Services [CMS] gap coveragerules) until their true out-of-pocket costreaches the catastrophic stage.8-52014 Practitioner and Provider Manual - Ver. 3