PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II SECTION Chapter 5: 3 Using What the benefi plan’s ts are coverage not covered for your by the Part plan? D prescription drugs SECTION 6 WHAT IF YOUR COVERAGE CHANGES FOR ONE OF YOUR DRUGS? Section 6.1 The Drug List can change during the year Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might: • Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineff ective. • Move a drug to a higher or lower cost-sharing tier. • Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 5 in this chapter). • Replace a brand name drug with a generic drug. In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. Section 6.2 What happens if coverage changes for a drug you are taking? How will you fi nd out if your drug’s coverage has been changed? If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. Your provider will also know about this change, and can work with you to fi nd another drug for your condition. Do changes to your drug coverage affect you right away? If any of the following types of changes aff ect a drug you are taking, the change will not aff ect you until January 1 of the next year if you stay in the plan: • If we move your drug into a higher cost-sharing tier. • If we put a new restriction on your use of the drug. • If we remove your drug from the Drug List, but not because of a sudden recall or because a new generic drug has replaced it. If any of these changes happens for a drug you are taking, then the change won’t aff ect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes will aff ect you. In some cases, you will be aff ected by the coverage change before January 1: 95
96 2013 Evidence of Cover age for PPO II Chapter 5: Using the plan’s coverage for your Part D prescription drugs • If a brand name drug you are taking is replaced by a new generic drug, the plan must give you at least 60 days’ notice or give you a 60-day refi ll of your brand name drug at a network pharmacy. � During this 60-day period, you should be working with your provider to switch to the generic or to a diff erent drug that we cover. � Or you and your provider can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). • Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. � Your provider will also know about this change, and can work with you to fi nd another drug for your condition. SECTION 7 WHAT TYPES OF DRUGS ARE NOT COVERED BY THE PLAN? Section 7.1 Types of drugs we do not cover Th is section tells you what kinds of prescription drugs are “excluded.” Th is means Medicare does not pay for these drugs. If you get drugs that are excluded, you must pay for them yourself. We won’t pay for the drugs that are listed in this section Th e only exception: If the requested drug is found upon appeal to be a drug that is not excluded under Part D and we should have paid for or covered it because of your specifi c situation. (For information about appealing a decision we have made to not cover a drug, go to Chapter 9, Section 6.5 in this booklet.) Here are three general rules about drugs that Medicare drug plans will not cover under Part D: • Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. • Our plan cannot cover a drug purchased outside the United States and its territories. • Our plan usually cannot cover off -label use. “Off -label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration. � Generally, coverage for “off -label use” is allowed only when the use is supported by certain reference books. Th ese reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or
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