PPO II - EmblemHealth

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� Some vaccines are considered medical benefi ts. You can fi nd out about your coverage of these
vaccines by going to Chapter 4, Medical Benefi ts Chart (what is covered and what you pay).
� Other vaccines are considered Part D drugs. You can fi nd these vaccines listed in the
plan’s List of Covered Drugs (Formulary).
2. Where you get the vaccine medication.
2013 Evidence of Coverage for PPO II
Chapter 6: What you pay for your Part D prescription drugs
3. Who gives you the vaccination shot.
What you pay at the time you get the Part D vaccination can vary depending on the circumstances.
For example:
• Sometimes when you get your vaccination shot, you will have to pay the entire cost for both the
vaccine medication and for getting the vaccination shot. You can ask our plan to pay you back
for our share of the cost.
• Other times, when you get the vaccine medication or the vaccination shot, you will pay only
your share of the cost.
To show how this works, here are three common ways you might get a Part D vaccination shot.
Remember you are responsible for all of the costs associated with vaccines (including their
administration) during the Coverage Gap Stage of your benefi t.
Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the
network pharmacy. (Whether you have this choice depends on where you live. Some
states do not allow pharmacies to administer a vaccination.)
• You will have to pay the pharmacy the amount of your coinsurance/
copayment for the vaccine itself.
• Our plan will pay for the cost of giving you the vaccination shot.
Situation 2: You get the Part D vaccination at your doctor’s offi ce.
• When you get the vaccination, you will pay for the entire cost of the vaccine
and its administration.
• You can then ask our plan to pay our share of the cost by using the
procedures that are described in Chapter 7 of this booklet (Asking us to pay
our share of a bill you have received for covered medical services or drugs).
• You will be reimbursed the amount you paid less your normal coinsurance/
copayment for the vaccine (including administration) less any diff erence
between the amount the doctor charges and what we normally pay. (If you
get Extra Help, we will reimburse you for this diff erence.)
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s offi ce
where they give you the vaccination shot.
• You will have to pay the pharmacy the amount of your coinsurance/
copayment for the vaccine itself.
• When your doctor gives you the vaccination shot, you will pay the entire