This page will give you general information about Medicare Part D prescription drug coverage and how to access the benefit with the Peoples Health plans. We’ll start first with some basic questions and answers. More details on Medicare prescription drug coverage are available from Medicare at www.medicare.gov.
Questions About Part D Prescription Drug Coverage
Questions About Prescription Drug Coverage & Peoples Health Health Plans
Grievance, Exceptions, Coverage Determinations and Appeals Procedures
Peoples Health Service Area
Links to Plan Documents
Questions About Part D Prescription Drug Coverage
What is Medicare prescription drug coverage?
Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs.
Who can get Medicare prescription drug coverage?
Everyone with Medicare is eligible for this coverage regardless of income and resources, health status, or current prescription expenses.
When can I get Medicare prescription drug coverage?
If you are new to Medicare or have lost creditable prescription drug coverage (like that provided by some employer or union plans) - you may be eligible to enroll now. Otherwise, each year from November 15 to December 31 you can switch to a different Medicare drug plan if your needs change.
How does Medicare prescription drug coverage work?
Your decision about Medicare prescription drug coverage depends on the kind of healthcare coverage you have now. There are two ways to get Medicare prescription drug coverage. You can join a Medicare prescription drug plan or you can join a Medicare Advantage Plan or other Medicare health plans that offer drug coverage. As a member of a Peoples Health Medicare health plan, you are automatically enrolled in the Medicare prescription drug plan.
Whatever plan you choose, Medicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you.
The health plans offered by Peoples Health have no additional monthly premium for drug coverage and no initial deductible.
What if I have a limited income and resources?
There is extra help for people with limited income and resources. Almost 1 in 3 people with Medicare will qualify for extra help and Medicare will pay for almost all of their prescription drug costs.
For more information on who can get extra help with prescription drug costs and how to apply, call the Social Security Administration (SSA) toll-free at (800) 772-1213 or visit www.socialsecurity.gov on the Web. TTY/TDD users should call (800) 325-0778.
In addition, you can look at the 2008 Medicare & You Handbook, visit www.medicare.gov on the Web, or call 1-800-MEDICARE (800) 633-4227). TTY/TDD users should call (877) 486-2048.
You may also call Peoples Health Member Services Department toll-free at (800) 631-8443, Monday through Friday from 8 a.m. to 8 p.m. TTY/TDD users should call toll-free (888) 631-9979.
Questions About Prescription Drug Coverage Peoples Health Health Plans
How do I fill a prescription at a network pharmacy?
To fill your prescription, you must show your Peoples Health Member ID card at one of our network (preferred or non-preferred) pharmacies. If you do not have your ID card with you when you fill your prescription, you may have to pay the full cost of the prescription (rather than paying just your copayment).
If this happens, you can ask us to reimburse you for our share of the cost by submitting a claim to us. To find out how to submit a claim, please look in your Evidence of Coverage or call Member Services toll-free at the number located at the top of the screen.
Your out-of-pocket costs are lower when you utilize network pharmacies.
We call the pharmacies on this list our "network pharmacies (preferred and non-preferred)" because we have made arrangements with them to provide prescription drugs to plan members. A network pharmacy is a pharmacy where beneficiaries obtain prescription drug benefits provided by Peoples Health. In some cases, your prescriptions are covered under Peoples Health only if they are filled at a preferred network pharmacy or through our mail order pharmacy service. Once you go to one, you are not required to continue going to the same pharmacy to fill your prescription, you can go to any of our network pharmacies.
We will fill prescriptions at non-network pharmacies under certain circumstances, which we describe later.
How do I fill a prescription through mail-order?
To utilize the Peoples Health mail-order service, you must complete a Mail-Order Prescription Drug Form. Please call Member Services to request the form or click here to download an electronic version. For more information regarding mail-order (maintenance) prescription drugs, please refer to the Evidence of Coverage. Please note that you must use the Peoples Health mail-order service. Prescription drugs that you obtain through any other mail-order service are not covered.
When you order non-controlled maintenance prescription drugs by mail, you will receive up to a 90-day supply of the drug. You are not required to use mail-order prescription drug services to obtain an extended supply of maintenance medications. Instead, you have the option of using a preferred network retail pharmacy to obtain a maintenance supply of medications. Please look in the Evidence of Coverage or call Member Services toll-free at the number located at the top of this page.
Filling a prescription outside the network
We have network pharmacies outside of the service area where you can get your drugs covered as a member of our plans. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Here are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill a prescription at an out-of-network pharmacy, please call Member Services to see if there is a network pharmacy available.
What if I need a prescription because of a medical emergency?
Our pharmacy network extends beyond our service area and throughout the United States. For example, you can fill prescriptions anywhere in the country with your ID Card at any drug store chain listed in our Provider Directory. We will cover prescriptions that are filled at any out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your copay) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Member Services can provide you with the form necessary to submit the claim.
Getting coverage when you travel or are away from the plan's service area
If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our network mail-order pharmacy service or through a retail network pharmacy that offers an extended supply.
If you are traveling within the U.S., but outside of the plan's service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. In this situation, you will have to pay the full cost (rather than paying just your copay) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form.
You have prescription drug coverage at network (preferred and non-preferred) and out-of-network pharmacies within the United States and its territories. Your out-of-pocket costs will be lower if you utilize preferred network pharmacies. However, we cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.
Prior to filling your prescription at an out-of-network pharmacy, call Member Services to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.
We cannot pay for any prescriptions that are filled in pharmacies outside the United States, even for a medical emergency, with outpatient prescription drug coverage. Peoples Health does provide worldwide coverage for both emergency and urgently needed care up to an annual maximum of $5,000. Please refer to Section 4 for details.
Other times you can get your prescription covered if you go to an out-of-network pharmacy
We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:
• If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
• If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy.
• Prescriptions for a 30-day supply will be reimbursed based upon our contracted discount rate and not on the amount paid to the pharmacy. In addition, a copay will be included.
• Prescriptions for more than a 30-day supply will be reimbursed based upon our contracted discount rate and not on the amount paid to the pharmacy. A copay will also be included.
All other limitations, such as early refills and quantity limits that would have applied if the prescription was filled at a network pharmacy apply to out-of-network pharmacies.
What is the Peoples Health Formulary?
A formulary is a list of drugs selected by Peoples Health in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Peoples Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Peoples Health network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
To search the Peoples Health Comprehensive Formulary, click here.
Can the Formulary change?
Yes, Peoples Health may add or remove drugs from our formulary during the year. For updated information about the drugs covered by Peoples Health, please call Member Services at the numbers listed at the end of this section.
If Peoples Health removes drugs from our formulary, adds prior authorization, quantity limits and/or step therapy restrictions on a drug or moves a drug to a higher cost-sharing level, we must notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
How much will I pay for Peoples Health Covered Drugs?
If you qualified for extra help with your drug costs, your costs for your drugs may be different than those described below. Please refer to your Evidence of Coverage or call Member Services to find out what your costs are.
The amount you pay depends on which drug level your drug is in under our plan and whether you fill your prescription at a preferred network pharmacy.
Click here to search by plan.
You will pay a copayment/coinsurance for your drugs until your out-of-pocket drugs costs reach $4,050 in 2008. After that, you will generally pay the greater of either $2.25 for generics and $5.60 for brand-name drugs or 5% coinsurance.
Note: A 90-day supply of drugs at non-preferred network or out-of-network pharmacies may be available. In these cases, you will be asked to pay the full cost of the prescription. You can then ask us to reimburse you for our share of the cost by submitting a claim to us, using the Direct Member Reimbursement form with appropriate documentation. Member Services can provide you with the necessary form. You will be reimbursed at the preferred, discounted rate. In addition, copays will be deducted from the reimbursement. Please refer to your Evidence of Coverage or call Member Services for more details.
Click here to search for Network Pharmacies.
Can the list of network pharmacies change?
Yes, Peoples Health may add or remove pharmacies from our Provider Directory. For the most up-to-date information about our network pharmacies in your area, please call Member Services Department at the numbers listed at the top of this page.
Are there any other restrictions on coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization:
Peoples Health requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval from Peoples Health before you fill your prescriptions. If you don't get approval, Peoples Health may not cover the drug. Your physician can use this form and fax it to (504) 468-3611 to request a prior authorization.
What if my drug is not on the Formulary?
If your drug is not included in the Abridged Formulary (PDF file - 3.04 MB), which was mailed to your house, please check our Comprehensive Formulary, or contact Member Services to be sure it is not covered.
If you learn that Peoples Health does not cover your drug, you have two options:
1) You may ask Member Services for a list of similar drugs that are covered by Peoples Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Peoples Health.
2) You can also request an exception to the Peoples Health Formulary; more details on how to request an exception are listed below.
Transition Policy
New members in Peoples Health may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage determination) in order to get coverage for the drug. See Section 10 (under “What is an exception”) to learn more about how to request an exception. Please call Member Services at the number listed in Section 1 if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy or will no longer be on our formulary next year, and you need help switching to an appropriate drug that we cover or requesting a formulary exception.
During the period of time members are talking with their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in Peoples Health. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year.
For each of the drugs that isn’t on our formulary or that has coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy and the drug is otherwise a “Part D drug”. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again.
If a new member is a resident of a long-term care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in Peoples Health, when that member is a resident of a long-term care facility. If a new member who is a resident of a long-term care facility needs a drug that isn’t on our formulary or subject to other restrictions, such as step therapy or dosage limits, but the new member has been enrolled in our plan for more than 90 days, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy couldn’t be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.
How do I request an exception to the Peoples Health Formulary?
You can ask Peoples Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Peoples Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, Peoples Health will only approve your request for an exception if the alternative drugs included on the plan's formulary, the low-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of your request.
What are generic drugs?
Peoples Health covers both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
Medical Management
Medical Management is an important component of promoting cost-effective, high-quality healthcare. Through the process of authorization, prospective, concurrent and retrospective review and care management, licensed physicians, pharmacists and nurses evaluate the services provided to Peoples Health health plan members to be sure they are medically necessary and appropriate for the condition and/or setting.
Improving Healthcare Quality with the Quality Improvement Program
Peoples Health, Inc. is always working to improve the quality of healthcare and customer service we offer our members. By following strict standards of care and monitoring the delivery of that care, we are able to measure our success. Our Quality Improvement team plans and implements programs to improve the delivery of care and ensure positive health outcomes for members. Upon your request, we will mail you information about our Quality Improvement program, including a description of the program and a report on our progress toward meeting our goals. Please call Member Services if you are interested.
Affirmative Statement About Incentives
Medical management is the process that promotes high quality healthcare in a cost-effective manner.
It is the policy of Peoples Health that financial incentives are not used to encourage barriers to care or service. Peoples Health does not encourage decisions that may result in under- or over-utilization in medical or behavioral health services.
Decision-making in the medical management process is based only on the appropriateness of care, service and existing coverage.
Peoples Health does not reward its physicians, nurses or pharmacists who perform utilization review for issuing denials in the provision of care or service.
To ensure that appropriate decision making occurs in the medical management arena, Peoples Health monitors data and information for under- and over-utilization.
Grievance, Exceptions, Coverage Determinations and Appeals Procedures
What is a coverage determination?
A decision about whether we will cover a Part D prescription drug is considered a coverage determination. If your doctor or pharmacist tells you that Peoples Health will not cover a prescription drug, you should contact us and ask for a coverage determination. Examples of a coverage determination are:
• If you are not getting a prescription drug that you believe may be covered by Peoples Health;
• If you have received a Part D prescription drug you believe may be covered by Peoples Health while you were a member, but we have refused to pay for the drug;
• If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our list of covered drugs (called a "formulary"). You can request an exception to our formulary (see "How do I request an exception" for more information).
• If you disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you. You can request an exception to the copayment we require you to pay for a drug (see "How do I request an exception" for more information).
• If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
• If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.
• If there is a requirement that you try another drug before we will pay for the drug you are requesting.
• You bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense.
You can ask us for a coverage determination yourself or your prescribing physician or someone you name may do it for you. Click here for a link to our Coverage Determination form - the form can be filled out and sent to us via U.S. mail or faxed using the contact information listed below. The person you name would be your "appointed representative." You can name a relative, friend, advocate, doctor, or anyone else to act for you. The Evidence of Coverage provides more details on coverage determinations.
What are appeals and grievances?
You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "grievances" are the two different types of complaints you can make. If you are unhappy with the coverage determination, you can ask for an appeal.
Appeals
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about Part D prescription drug benefits that are covered for you or what we will pay for a prescription drug.
You can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug that you paid for. You can also appeal if you think we should have reimbursed you more than you received or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription. Finally, if we deny your exception request (see how to request an exception), you can appeal.
The Evidence of Coverage provides more details on how to file an appeal; links to this document are available at the end of this page.
After we receive your appeal, we have up to 7 calendar days to give you a standard decision, but will make it sooner if your health condition requires us to. If we do not give you our decision within 7 calendar days, your request will automatically go to the second level of appeal, where an independent organization will review your case. For a fast decision, we have up to 72 hours to give you a decision, but will make it sooner if your health requires us to. If we do not give you a decision within 72 hours, your request will automatically go to the second level of appeal, where an independent organization will review your case.
If you are dissatisfied with the outcome, you or your appointed representative must make a request for review by the independent review organization in writing within 60 calendar days after the date you were notified of the decision on your first appeal. You must send your written request to the independent review organization whose name and address is included in the redetermination you receive from Peoples Health.
Grievances
A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Peoples Health or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy.
We encourage you to first call Member Services at the numbers listed at the end of this section. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints.
If you are not satisfied with our response or if we cannot resolve your complaint over the phone, you may continue with the formal grievance process described below:
Formal Grievance procedures
Peoples Health formal grievance procedures are as follows:
1. Written inquiries should be directed to Peoples Health Member Services (Attention: Appeals Grievances Coordinator). You may ask what the procedures and timeframes are for responding to your complaint. All inquiries will be acknowledged within five working days by a letter from the Appeals Grievances Coordinator
2. You will be notified in writing of our decision regarding your grievance or of the status of the review within 30 days of the date the grievance was received. Final resolution will be made no later than 30 days after the grievance was received. In some instances we will need additional time to address your concern. If additional time is needed, we will keep you informed of how your grievance is being handled.
3. If you are dissatisfied with the response to your inquiry, you can request a review in writing to Peoples Health. Your review request may include written information from you or any other party of interest. You must submit the review request within 60 days of receiving the original resolution.
4. Peoples Health Member Services will direct your review request to the appropriate committee who will reconsider your written complaint and respond in writing within 30 days of receipt of your request for review.
5. If you wish to appeal the decision of the Peoples Health committee, your next step will be to submit the dispute to binding arbitration in Jefferson Parish, State of Louisiana, under the prevailing commercial arbitration rules of the American Arbitration Association (AAA) and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Any party desiring arbitration shall serve written notice thereof. Regulatory orders and/or requirements shall not be subject to arbitration. The demand shall be made within a reasonable time after the claim, dispute or other matter in question has arisen. The arbitrator shall have the authority and the power to render any judgement or relief available to a civil judge acting in Louisiana including, without limitation, monetary damages, injunctive relief, attorney's fees and costs to the prevailing party, etc.
For further information regarding the purpose and operations of the grievance procedure, contact the following:
Peoples Health Member Services Department
ATTN: Appeals & Grievances Coordinator
Three Lakeway Center
3838 N. Causeway Blvd., Suite 2200
Metairie, LA 70002
Monday through Friday, 8:00 a.m. to 8:00 p.m.
(504) 849-4500, Ext. 2 Local
(800) 631-8443, Ext. 2 Toll-free
(504) 849-6906 Fax
(888) 631-9979 Telephone Device for the Hearing Impaired
Request for Medicare Prescription Drug Coverage Determination or Exception (PDF file - 325 KBytes)
Request for an Appeal, Grievance, or Redetermination (PDF file - 133 KBytes)
Pharmacy Prior Authorization/Non-Formulary Request (PDF file - 153 KBytes)
Request for Appointment of Representative (PDF file - 66 KBytes)
Peoples Health Service Area
Choices 65
The Medicare-approved service area for Choices 65 is defined as the parishes of Jefferson, Orleans, Plaquemines and St. Tammany.
Choices Plus
To be a member of Choices Plus, you must live in the Medicare-approved service area defined as Ascension, East Baton Rouge, Livingston, St. Bernard, St. Charles St. James, St. John, Tangipahoa, Washington, and West Baton Rouge parishes.
HealthCare Select
HealthCare Select's Medicare-approved service area is defined as the parishes of Jefferson, Orleans, Plaquemines, St. Bernard, St. Charles, St. John and St. Tammany.
Secure Health
To enroll in Secure Health, you must reside in the Medicare-approved service area defined as Ascension, East Baton Rouge, Jefferson, Livingston, Orleans, Plaquemines, St. Bernard, St. Charles, St. James, St. John, St. Tammany, Tangipahoa, Washington, and West Baton Rouge parishes.
Potential for Contract Termination
The health plans of Peoples Health, Inc. have contracts with the Centers for Medicare Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed and either Peoples Health, Inc. or CMS can decide to end it. You will get 90-days advance notice in this situation. It is possible for our contract to end at some other time during the year, too. In these situations we will try to tell you 90 days in advance, but your advance notice may be as little as 30 or fewer days if CMS must end our contract in the middle of the year.
Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you will be provided a special enrollment period to make choices about how you get Medicare, including choosing a Medicare Prescription Drug Plan and guaranteed issue rights to a Medigap policy.
For more information
For more detailed information about your Peoples Health prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Peoples Health, please call Member Services toll-free at (800) 631-8443, Monday through Friday from 8 a.m. to 8 p.m. TTY/TDD users should call toll-free (888) 631-9979.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
Links to Plan Documents
(Links to each health plan’s documents: Summary of Benefits, Evidence of Coverage, Privacy Notice)
Choices 65
Choices Plus
HealthCare Select
Secure Health
OGB Group Medicare