PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II SECTION Chapter 5: 3 Using What the benefi plan’s ts are coverage not covered for your by the Part plan? D prescription drugs What if you need a specialized pharmacy? Sometimes prescriptions must be fi lled at a specialized pharmacy. Specialized pharmacies include: • Pharmacies that supply drugs for home infusion therapy. • Pharmacies that supply drugs for residents of a long-term care facility. Usually, a long-term care facility (such as a nursing home) has its own pharmacy. Residents may get prescription drugs through the facility’s pharmacy as long as it is part of our network. If your long-term care pharmacy is not in our network, please contact Customer Service. • Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these pharmacies in our network. • Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: Th is scenario should happen rarely.) To locate a specialized pharmacy, look in your Provider/Pharmacy Directory or call Customer Service (phone numbers are printed on the back cover of this booklet). Section 2.3 Using the plan’s mail-order services For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. Th e drugs that are not available through our plan’s mail-order service are marked as “MOE” (“mail order excluded”) drugs in our Drug List. Our plan’s mail-order service requires you to order at least a 30-day supply of the drug and no more than a 90-day supply. To get order forms and information about fi lling your prescriptions by mail you can: • Download the form by going to our website at www.emblemhealth.com/medicare. • Call our Customer Service (phone numbers are on the back cover of this booklet).. Usually a mail-order pharmacy order will get to you in no more than 14 days. Section 2.4 How can you get a long-term supply of drugs? When you get a long-term supply of drugs, your cost sharing may be lower. Th e plan off ers two ways to get a long-term supply of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) 1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Some of these retail pharmacies agree to accept a lower cost-sharing amount for a long-term supply of maintenance drugs. Other retail pharmacies may not agree to accept the lower cost-sharing amounts for a long-term supply of maintenance drugs. In this case you will be responsible for the diff erence in price. Your Provider/Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You can also call Customer Service for more information (phone numbers are printed on the back cover of this booklet). 87
88 2013 Evidence of Cover age for PPO II Chapter 5: Using the plan’s coverage for your Part D prescription drugs 2. For certain kinds of drugs, you can use the plan’s network mail-order services. Th e drugs that are not available through our plan’s mail-order service are marked as “MOE” (“mail order excluded”) drugs in our Drug List. Our plan’s mail-order service requires you to order at least a 30-day supply of the drug and no more than a 90-day supply. See Section 3.3 for more information about using our mail-order services. Section 2.5 When can you use a pharmacy that is not in the plan’s network? Your prescription may be covered in certain situations We have network pharmacies outside of our service area where you can get your prescriptions fi lled as a member of our plan. Generally, we cover drugs fi lled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions fi lled at an out-of-network pharmacy: • If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provides 24 hour service. • If you are trying to fi ll a prescription drug that is not regularly stocked at an accessible network, retail or mail-order pharmacy (including high-cost and unique drugs). • If you are getting a vaccine that is medically necessary but not covered by Medicare Part B or some covered drugs that are administered in your doctor’s offi ce. In these situations, please check fi rst with Customer Service to see if there is a network pharmacy nearby. (Phone numbers for Customer Service are printed on the back cover of this booklet.) How do you ask for reimbursement from the plan? If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fi ll your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to pay you back.)
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