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 SECTION 3 YOUR DRUGS NEED TO BE ON THE PLAN’S “DRUG LIST” Section 3.1 The “Drug List” tells which Part D drugs are covered Th e plan has a “List of Covered Drugs (Formulary).” In this Evidence of Coverage, we call it the “Drug List” for short. Th e drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. Th e list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. Th e drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter, Section 1.1 explains about Part D drugs). We will generally cover a drug on the plan’s Drug List as long as you follow the other coverage rules explained in this chapter and the use of the drug is a medically accepted indication. A “medically accepted indication” is a use of the drug that is either: • approved by the Food and Drug Administration. (Th at is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) • -- or -- supported by certain reference books. (Th ese reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor.) The Drug List includes both brand name and generic drugs A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. Th ere are generic drug substitutes available for many brand name drugs. What is not on the Drug List? Th e plan does not cover all prescription drugs. • In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more about this, see Section 8.1 in this chapter). • In other cases, we have decided not to include a particular drug on our Drug List. Section 3.2 There are four “cost-sharing tiers” for drugs on the Drug List Every drug on the plan’s Drug List is in one of four cost-sharing tiers. In general, the higher the costsharing tier, the higher your cost for the drug: • Tier 1 - Preferred Generic Drugs • Tier 2 - Preferred Brand Drugs • Tier 3 - Non-Preferred Brand Drugs • Tier 4 - Specialty Drugs 89
90 2013 Evidence of Cover age for PPO II Chapter 5: Using the plan’s coverage for your Part D prescription To fi nd out which cost-sharing tier your drug is in, look it up in the plan’s Drug List. Th e amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay for your Part D prescription drugs). Section 3.3 How can you fi nd out if a specifi c drug is on the Drug List? You have three ways to fi nd out: 1. Check the most recent Drug List we sent you in the mail. 2. Visit the plan’s website (www.emblemhealth.com/medicare). Th e Drug List on the website is always the most current. 3. Call Customer Service to fi nd out if a particular drug is on the plan’s Drug List or to ask for a copy of the list. (Phone numbers for Customer Service are printed on the back cover of this booklet.) SECTION 4 THERE ARE RESTRICTIONS ON COVERAGE FOR SOME DRUGS Section 4.1 Why do some drugs have restrictions? For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most eff ective ways. Th ese special rules also help control overall drug costs, which keeps your drug coverage more aff ordable. In general, our rules encourage you to get a drug that works for your medical condition and is safe and eff ective. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use the formal appeals process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information about asking for exceptions.) Section 4.2 What kinds of restrictions? Our plan uses diff erent types of restrictions to help our members use drugs in the most eff ective ways. Th e sections below tell you more about the types of restrictions we use for certain drugs. Restricting brand name drugs when a generic version is available Generally, a “generic” drug works the same as a brand name drug and usually costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that the generic drug will not work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.)
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PPO II - EmblemHealth

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