PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Chapter 2: Important phone numbers and resources • For individuals who are not deemed eligible but who apply and are found LIS eligible, a copy of the SSA award letter. When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will off set future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Customer Service if you have questions (phone numbers are printed on the back cover of this booklet). Medicare Coverage Gap Discount Program Th e Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enrollees who have reached the coverage gap and are not already receiving “Extra Help.” A 50% discount on the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) is available for those brand name drugs from manufacturers that have agreed to pay the discount. Th e plan pays an additional 2.5% and you pay the remaining 47.5% for your brand drugs. If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your Explanation of Benefi ts (EOB) will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays 21% of the price for generic drugs and you pay the remaining 79% of the price. Th e coverage for generic drugs works diff erently than the coverage for brand name drugs. For generic drugs, the amount paid by the plan (21%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug. If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Service (phone numbers are printed on the back cover of this booklet). What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)? If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than Extra Help), you still get the 50% discount on covered brand name drugs. Also, the plan pays 2.5% of the costs of brand drugs in the coverage gap. Th e 50% discount and the 2.5% paid by the plan is applied to the price of the drug before any SPAP or other coverage. What if you get Extra Help from Medicare to help pay your prescription drug costs? Can you get the discounts? No. If you get Extra Help, you already get coverage for your prescription drug costs during the coverage gap. 29
30 2013 Evidence of Coverage for PPO II Chapter 2: Important phone numbers and resources What if you don’t get a discount, and you think you should have? If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you should review your next Explanation of Benefi ts (EOB) notice. If the discount doesn’t appear on your Explanation of Benefi ts, you should contact us to make sure that your prescription records are correct and up-to-date. If we don’t agree that you are owed a discount, you can appeal. You can get help fi ling an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this Chapter) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. State Pharmaceutical Assistance Programs Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on fi nancial need, age, or medical condition. Each state has diff erent rules to provide drug coverage to its members. Th ese programs provide limited income and medically needy seniors and individuals with disabilities fi nancial help for prescription drugs. In New York State, the State Pharmaceutical Assistance Program is the Elderly Pharmaceutical Insurance Coverage Program (EPIC) . Elderly Pharmaceutical Insurance Coverage Program (EPIC) (New York’s State Pharmaceutical Assistance Program) CALL 1-800-332-3742 TTY 1-800-290-9138 This number requires special telephone equipment and is only for people who have diffi culties with hearing or speaking. WRITE EPIC P.O. Box 15018 Albany, NY 12212-5018 WEBSITE www.health.state.ny.us/health_care/epic
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PPO II - EmblemHealth

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