PPO II - EmblemHealth

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2013 Evidence of Coverage for <strong>PPO</strong> <strong>II</strong> Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs SECTION 4 OTHER SITUATIONS IN WHICH YOU SHOULD SAVE YOUR RECEIPTS AND SEND COPIES TO US Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs Th ere are some situations when you should let us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we can calculate your out-of-pocket costs correctly. Th is may help you to qualify for the Catastrophic Coverage Stage more quickly. Here are two situations when you should send us copies of receipts to let us know about payments you have made for your drugs: 1. When you buy the drug for a price that is lower than our price Sometimes when you are in Coverage Gap Stage you can buy your drug at a network pharmacy for a price that is lower than our price. • For example, a pharmacy might off er a special price on the drug. Or you may have a discount card that is outside our benefi t that off ers a lower price. • Unless special conditions apply, you must use a network pharmacy in these situations and your drug must be on our Drug List. • Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. • Please note: If you are in the Coverage Gap Stage, we will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly. 2. When you get a drug through a patient assistance program offered by a drug manufacturer Some members are enrolled in a patient assistance program off ered by a drug manufacturer that is outside the plan benefi ts. If you get any drugs through a program off ered by a drug manufacturer, you may pay a copayment to the patient assistance program. • Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. • Please note: Because you are getting your drug through the patient assistance program and not through the plan’s benefi ts, we will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly. Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Th erefore, you cannot make an appeal if you disagree with our decision. 127
128 2011 Evidence of Coverage for HMO Medicare Supplement (Cost) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs
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