PPO II - EmblemHealth

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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