PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II SECTION Chapter 6: 3 What you benefi pay ts for are your not covered Part D prescription by the plan? drugs Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs for your drugs. These payments are included in your out-of-pocket costs When you add up your out-of-pocket costs, you can include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 5 of this booklet): • Th e amount you pay for drugs when you are in any of the following drug payment stages: – Th e Initial Coverage Stage. – Th e Coverage Gap Stage. • Any payments you made during this calendar year as a member of a diff erent Medicare prescription drug plan before you joined our plan. It matters who pays: • If you make these payments yourself, they are included in your out-of-pocket costs. • Th ese payments are also included if they are made on your behalf by certain other individuals or organizations. Th is includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutical Assistance Program, or by the Indian Health Service that is qualifi ed by Medicare. Payments made by Medicare’s “Extra Help” Program are also included. • Some of the payments made by the Medicare Coverage Gap Discount Program are included. Th e amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included. Moving on to the Catastrophic Coverage Stage: When you (or those paying on your behalf) have spent a total of $4,750 in out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage. 111
112 These payments are not included in your out-of-pocket costs 2013 Evidence of Coverage for PPO II Chapter 6: What you pay for your Part D prescription drugs When you add up your out-of-pocket costs, you are not allowed to include any of these types of payments for prescription drugs: • Th e amount you pay for your monthly premium. • Drugs you buy outside the United States and its territories. • Drugs that are not covered by our plan. • Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements for out-of-network coverage. • Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from coverage by Medicare. • Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan. • Payments made by the plan for your generic drugs while in the Coverage Gap. • Payments for your drugs that are made by group health plans including employer health plans. • Payments for your drugs that are made by certain insurance plans and government-funded health programs such as TRICARE and the Veteran’s Administration. • Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Worker’s Compensation). Reminder: If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for drugs, you are required to tell our plan. Call Customer Service to let us know (phone numbers are on the back cover of this booklet). How can you keep track of your out-of-pocket total? • We will help you. Th e Explanation of Benefi ts (EOB) report we send to you includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $4,750 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. • Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date.
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