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 ? Did you know there are programs to help people pay for their drugs? Th ere are programs to help people with limited resources pay for their drugs. Th ese include “Extra Help” and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7. Are you currently getting help to pay for your drugs? If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Customer Service and ask for the “LIS Rider.” (Phone numbers for Customer Service are printed on the back cover of this booklet.) SECTION 1 INTRODUCTION Section 1.1 This chapter describes your coverage for Part D drugs Th is chapter explains rules for using your coverage for Part D drugs. Th e next chapter tells what you pay for Part D drugs (Chapter 6, What you pay for your Part D prescription drugs). In addition to your coverage for Part D drugs, our plan also covers some drugs under the plan’s medical benefi ts: • Th e plan covers drugs you are given during covered stays in the hospital or in a skilled nursing facility. Chapter 4 (Medical Benefi ts Chart, what is covered and what you pay) tells about the benefi ts and costs for drugs during a covered hospital or skilled nursing facility stay. • Medicare Part B also provides benefi ts for some drugs. Part B drugs include certain chemotherapy drugs, certain drug injections you are given during an offi ce visit, and drugs you are given at a dialysis facility. Chapter 4 (Medical Benefi ts Chart, what is covered and what you pay) tells about your benefi ts and costs for Part B drugs. Th e two examples of drugs described above are covered by the plan’s medical benefi ts. Th e rest of your prescription drugs are covered under the plan’s Part D benefi ts. Section 1.2 Basic rules for the plan’s Part D drug coverage Th e plan will generally cover your drugs as long as you follow these basic rules: • You must have a provider (a doctor or other prescriber) write your prescription. 85
86 2013 Evidence of Cover age for PPO II Chapter 5: Using the plan’s coverage for your Part D prescription drugs • You must use a network pharmacy to fi ll your prescription. (See Section 3, Fill your prescriptions at a network pharmacy or through the plan’s mail-order service].) • Your drug must be on the plan’s List of Covered Drugs (Formulary) (we call it the “Drug List” for short). (See Section 4, Your drugs need to be on the plan’s “Drug List.”) • Your drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 4 for more information about a medically accepted indication.) SECTION 2 FILL YOUR PRESCRIPTION AT A NETWORK PHARMACY OR THROUGH THE PLAN’S MAIL-ORDER SERVICE Section 2.1 To have your prescription covered, use a network pharmacy In most cases, your prescriptions are covered only if they are fi lled at the plan’s network pharmacies. (See Section 3.5 for information about when we would cover prescriptions fi lled at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. Th e term “covered drugs” means all of the Part D prescription drugs that are covered on the plan’s Drug List. Section 2.2 Finding network pharmacies How do you fi nd a network pharmacy in your area? To fi nd a network pharmacy, you can look in your Provider/Pharmacy Directory, visit our website (www.emblemhealth.com/medicare), or call Customer Service (phone numbers are printed on the back cover of this booklet). Choose whatever is easiest for you. You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refi ll of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy. What if the pharmacy you have been using leaves the network? If the pharmacy you have been using leaves the plan’s network, you will have to fi nd a new pharmacy that is in the network. To fi nd another network pharmacy in your area, you can get help from Customer Service (phone numbers are printed on the back cover of this booklet) or use the Provider/Pharmacy Directory. You can also fi nd information on our website at www.emblemhealth.com/medicare.
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