PPO II - EmblemHealth

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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 83
84 2011 Evidence of Coverage 2013 for HMO Evidence Medicare of Cover Supplement age for PPO (cost) II Chapter 5: Using the plan’s coverage for your Part D prescription drugs SECTION 6 What if your coverage changes for one of your drugs? ................. 95 Section 6.1 Th e Drug List can change during the year ..................................................................95 Section 6.2 What happens if coverage changes for a drug you are taking? .....................................95 SECTION 7 What types of drugs are not covered by the plan? .........................96 Section 7.1 Types of drugs we do not cover ..................................................................................96 SECTION 8 Show your plan membership card when you fi ll a prescription .... 97 Section 8.1 Show your membership card ......................................................................................97 Section 8.2 What if you don’t have your membership card with you? ...........................................97 SECTION 9 Part D drug coverage in special situations ....................................... 98 Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by the plan? ....................................................................................98 Section 9.2 What if you’re a resident in a long-term care facility? ..................................................98 Section 9.3 What if you’re also getting drug coverage from an employer or retiree group plan? .....99 SECTION 10 Programs on drug safety and managing medications ....................99 Section 10.1 Programs to help members use drugs safely ................................................................99 Section 10.2 Programs to help members manage their medications ..............................................100
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PPO II - EmblemHealth

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