PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II
Chapter 5: Using the plan’s coverage for your Part D prescription drugs
Chapter 5. Using the plan’s coverage for your Part D
prescription drugs
SECTION 1 Introduction ........................................................................................... 85
Section 1.1 Th is chapter describes your coverage for Part D drugs ................................................85
Section 1.2 Basic rules for the plan’s Part D drug coverage ............................................................85
SECTION 2 Fill your prescription at a network pharmacy or
through the plan’s mail-order service ............................................... 86
Section 2.1 To have your prescription covered, use a network pharmacy .......................................86
Section 2.2 Finding network pharmacies ......................................................................................86
Section 2.3 Using the plan’s mail-order services ............................................................................87
Section 2.4 How can you get a long-term supply of drugs? ...........................................................87
Section 2.5 When can you use a pharmacy that is not in the plan’s network? ................................88
SECTION 3 Your drugs need to be on the plan’s “Drug List” ............................. 89
Section 3.1 Th e “Drug List” tells which Part D drugs are covered .................................................89
Section 3.2 Th ere are four “cost-sharing tiers” for drugs on the Drug List .....................................89
Section 3.3 How can you fi nd out if a specifi c drug is on the Drug List? ......................................90
SECTION 4 There are restrictions on coverage for some drugs ........................90
Section 4.1 Why do some drugs have restrictions? ........................................................................90
Section 4.2 What kinds of restrictions? .........................................................................................90
Section 4.3 Do any of these restrictions apply to your drugs? ........................................................91
SECTION 5 What if one of your drugs is not covered in the way
you’d like it to be covered? ................................................................. 92
Section 5.1 Th ere are things you can do if your drug is not covered in the way
you’d like it to be covered ........................................................................................92
Section 5.2 What can you do if your drug is not on the Drug List or if the drug
is restricted in some way? ........................................................................................92
Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? ..............94
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