PPO II - EmblemHealth
PPO II - EmblemHealth
PPO II - EmblemHealth
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88<br />
2013 Evidence of Cover age for <strong>PPO</strong> <strong>II</strong><br />
Chapter 5: Using the plan’s coverage for your Part D prescription drugs<br />
2. For certain kinds of drugs, you can use the plan’s network mail-order services. Th e drugs that<br />
are not available through our plan’s mail-order service are marked as “MOE” (“mail order<br />
excluded”) drugs in our Drug List. Our plan’s mail-order service requires you to order at<br />
least a 30-day supply of the drug and no more than a 90-day supply. See Section 3.3 for more<br />
information about using our mail-order services.<br />
Section 2.5 When can you use a pharmacy that is not in the plan’s network?<br />
Your prescription may be covered in certain situations<br />
We have network pharmacies outside of our service area where you can get your prescriptions fi lled as a<br />
member of our plan. Generally, we cover drugs fi lled at an out-of-network pharmacy only when you are<br />
not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions fi lled<br />
at an out-of-network pharmacy:<br />
• If you are unable to obtain a covered drug in a timely manner within our service area because<br />
there are no network pharmacies within a reasonable driving distance that provides 24 hour<br />
service.<br />
• If you are trying to fi ll a prescription drug that is not regularly stocked at an accessible network,<br />
retail or mail-order pharmacy (including high-cost and unique drugs).<br />
• If you are getting a vaccine that is medically necessary but not covered by Medicare Part B or<br />
some covered drugs that are administered in your doctor’s offi ce.<br />
In these situations, please check fi rst with Customer Service to see if there is a network pharmacy<br />
nearby. (Phone numbers for Customer Service are printed on the back cover of this booklet.)<br />
How do you ask for reimbursement from the plan?<br />
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than<br />
your normal share of the cost) when you fi ll your prescription. You can ask us to reimburse you for our<br />
share of the cost. (Chapter 7, Section 2.1 explains how to ask the plan to pay you back.)