PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II Chapter 6: What you pay for your Part D prescription drugs SECTION 3 WE SEND YOU REPORTS THAT EXPLAIN PAYMENTS FOR YOUR DRUGS AND WHICH PAYMENT STAGE YOU ARE IN Section 3.1 We send you a monthly report called the “Explanation of Benefi ts” (the “EOB”) Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions fi lled or refi lled at the pharmacy. Th is way, we can tell you when you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of: • We keep track of how much you have paid. Th is is called your “out-of-pocket” cost. • We keep track of your “total drug costs.” Th is is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan. Our plan will prepare a written report called the Explanation of Benefi ts (it is sometimes called the “EOB”) when you have had one or more prescriptions fi lled through the plan during the previous month. It includes: • Information for that month. Th is report gives the payment details about the prescriptions you have fi lled during the previous month. It shows the total drugs costs, what the plan paid, and what you and others on your behalf paid. • Totals for the year since January 1. Th is is called “year-to-date” information. It shows you the total drug costs and total payments for your drugs since the year began. Section 3.2 Help us keep our information about your drug payments up to date To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can help us keep your information correct and up to date: • Show your membership card when you get a prescription fi lled. To make sure we know about the prescriptions you are fi lling and what you are paying, show your plan membership card every time you get a prescription fi lled. 105 • Make sure we have the information we need. Th ere are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-ofpocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 7, Section 2 of this booklet.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs: � When you purchase a covered drug at a network pharmacy at a special price or using a discount card that is not part of our plan’s benefi t.
106 2013 Evidence of Coverage for PPO II Chapter 6: What you pay for your Part D prescription drugs � When you made a copayment for drugs that are provided under a drug manufacturer patient assistance program. � Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances. • Send us information about the payments others have made for you. Payments made by certain other individuals and organizations also count toward your out-of-pocket costs and help qualify you for catastrophic coverage. For example, payments made by a State Pharmaceutical Assistance Program, an AIDS drug assistance program, the Indian Health Service, and most charities count toward your out-of-pocket costs. You should keep a record of these payments and send them to us so we can track your costs. • Check the written report we send you. When you receive an Explanation of Benefi ts (an EOB) in the mail, please look it over to be sure the information is complete and correct. If you think something is missing from the report, or you have any questions, please call us at Customer Service (phone numbers are printed on the back cover of this booklet). Be sure to keep these reports. Th ey are an important record of your drug expenses. SECTION 4 THERE IS NO DEDUCTIBLE FOR PPO II Section 4.1 You do not pay a deductible for your Part D drugs Th ere is no deductible for PPO II. You begin in the Initial Coverage Stage when you fi ll your fi rst prescription of the year. See Section 5 for information about your coverage in the Initial Coverage Stage. SECTION 5 DURING THE INITIAL COVERAGE STAGE, THE PLAN PAYS ITS SHARE OF YOUR DRUG COSTS AND YOU PAY YOUR SHARE Section 5.1 What you pay for a drug depends on the drug and where you fi ll your prescription During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment OR coinsurance amount). Your share of the cost will vary depending on the drug and where you fi ll your prescription.
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PPO II - EmblemHealth

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