PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) • You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules. (For example, when your drug is on the plan’s List of Covered Drugs (Formulary) but we require you to get approval from us before we will cover it for you.) � Please note: If your pharmacy tells you that your prescription cannot be fi lled as written, you will get a written notice explaining how to contact us to ask for a coverage decision. • You ask us to pay for a prescription drug you already bought. Th is is a request for a coverage decision about payment. If you disagree with a coverage decision we have made, you can appeal our decision. Th is section tells you both how to ask for coverage decisions and how to request an appeal. Use the chart below to help you determine which part has information for your situation: Which of these situations are you in? Do you need a drug that isn’t on our Drug List or need us to waive a rule or restriction on a drug we cover? You can ask us to make an exception. (Th is is a type of coverage decision.) Start with Section 6.2 of this chapter Do you want us to cover a drug on our Drug List and you believe you meet any plan rules or restrictions (such as getting approval in advance) for the drug you need? You can ask us for a coverage decision. Skip ahead to Section 6.4 of this chapter. Section 6.2 What is an exception? Do you want to ask us to pay you back for a drug you have already received and paid for? You can ask us to pay you back. (Th is is a type of coverage decision.) Skip ahead to Section 6.4 of this chapter. Have we already told you that we will not cover or pay for a drug in the way that you want it to be covered or paid for? You can make an appeal. (Th is means you are asking us to reconsider.) Skip ahead to Section 6.5 of this chapter. If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. 161
162 2013 Evidence of Coverage for PPO II Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make: 1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary). (We call it the “Drug List” for short.) Legal Terms Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a “formulary exception.” • If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Tier 3. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 2. Removing a restriction on our coverage for a covered drug. Th ere are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 5 and look for Section 5). Legal Terms Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.” • Th e extra rules and restrictions on coverage for certain drugs include: � Being required to use the generic version of a drug instead of the brand name drug. � Getting plan approval in advance before we will agree to cover the drug for you. (Th is is sometimes called “prior authorization.”) � Being required to try a diff erent drug fi rst before we will agree to cover the drug you are asking for. (Th is is sometimes called “step therapy.”) � Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have. • If we agree to make an exception and waive a restriction for you, you can ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug List is in one of four cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. Legal Terms Asking to pay a lower preferred price for a covered non-preferred drug is sometimes called asking for a “tiering exception.” • If your drug is in Tier 3 you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 2. Th is would lower your share of the cost for the drug. • You cannot ask us to change the cost-sharing tier for any drug in Tier 4 – Specialty Drugs.
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