Part D Coverage

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 and Peoples Health Medicare Health Plans
  
• Peoples Health Service Area
  
• Links to Plan Documents

Questions About Part D Prescription Drug Coverage

What is Medicare prescription drug coverage (Part D)?

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?

You can join a prescription drug plan when you are first eligible for Medicare. Generally, people who are age 65 or older, some younger people with disabilities and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or transplant) are eligible for Medicare. If you have End-Stage Renal Disease, you are entitled to Medicare coverage the first day of the fourth month of dialysis, the first day of the first month of self-dialysis, the month an individual is admitted to a hospital for a kidney transplant or up to twleve months prior to the month of applying by Medicare (if dialysis began more than twleve months before).  People with ESRD are not eligible to enroll in a Medicare Advantage plan or a Medicare prescription drug plan unless  they have received a kidney transplant and no longer require regular dialysis to maintain life or they have recovered their native kidney function and no longer require regular dialysis to maintain life.

If you are already getting benefits from the Social Security Administration or the Railroad Retirement Board, you become eligible for Medicare or a Medicare prescription drug plan starting the first day of the month that you turn 65. If you are not receiving Social Security Administration, Railroad Retirement Board or disability benefits, you can enroll in Medicare or a Medicare prescription drug plan up to three months before your 65th birthday and no later than three months after the month of your birthday. You may also be eligible to enroll in a Medicare prescription drug plan if you have lost creditable prescription drug coverage. (Creditable prescription drug coverage is coverage that is at least as good as standard prescription drug coverage, like that provided by some employer or union plans.)

In most cases, if you don't join a Medicare prescription drug plan when you are first eligible for Medicare, your next chance to join a prescription drug plan (or switch prescription drug plans) will be during the Annual Enrollment Period, between November 15th and December 31st each year.

If you have both Medicare and Medicaid, you can change Medicare plans or Medicare prescription drug plans at any time. Secure Health (HMO) is the Peoples Health plan for people who have both Medicare and Medicaid.

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 plan that offers 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.

Most Peoples Health plans have no additional monthly plan premium for prescription drug coverage. Choices 65 (HMO) and Choices Plus (HMO-POS) plan members pay $0 each month for their medical and prescription drug coverage. Secure Health (HMO) plan members pay $0 each month for their medical and prescription drug coverage because they are covered by both Medicare and Medicaid. Choices Select (HMO-POS) plan members pay a plan premium of $90.60 each month, and this premium is for their medical coverage and their prescription drug coverage. Peoples Health Group Medicare (HMO-POS) plan members pay a plan premium determined by their individual employer groups, and this premium is for their medical and their prescription drug coverage.

All Peoples Health plan members, or others on their behalf, must continue to pay their monthly Medicare Part B premium. The health plans offered by Peoples Health have no initial deductible.

What if I have a limited income and resources or need extra help?

There is extra help for people with limited income and resources. Peoples Health can work with you to help you apply for extra help or Member Services help you if you believe your current extra help status is incorrect. You may call the Peoples Health Member Services department toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., with questions you may have about extra help. Telephone device for the hearing impaired users may call (888) 631-9979.

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, Monday through Friday, fron 7 a.m. to 7 p.m., or visit www.socialsecurity.gov on the Web. Telephone device for the hearing impaired users should call (800) 325-0778. For information about Medicare's requirements to apply for extra help, click here.

In addition, you can look at the 2010 Medicare & You Handbook by visiting www.medicare.gov on the Web, or calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. Telephone device for the hearing impaired users should call (877) 486-2048.

Questions About Prescription Drug Coverage with Peoples Health Medicare 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 copay).

If this happens, you can ask us to reimburse you for our share of the cost by submitting a paper claim to us. To find out how to submit a paper claim, please look in your Evidence of Coverage or call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.  

Your out-of-pocket costs are lower when you utilize network pharmacies. For a listing of our network pharmacies, click here.

• We call pharmacies "network pharmacies (preferred and non-preferred)" when we have made arrangements with them to provide prescription drugs to our plan members. A network pharmacy is a pharmacy where beneficiaries obtain prescription drug benefits provided by Peoples Health. A "preferred pharmacy" is a pharmacy where most members can obtain drugs 90-day supplies of maintenance drugs for lower costs. A "non-preferred" pharmacy has higher costs for 90-day supplies of maintenance drugs.
  
  In some cases, your prescriptions are covered under Peoples Health only if they are filled at a network pharmacy or through our mail-order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances, described later. 
  
  Once you go to one pharmacy, you are not required to continue going to the same pharmacy to fill your prescription. You can go to any of our network pharmacies.
  

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. You can use the mail-order service to obtain 90-day supplies of maintenance medication. 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 if you order a 90-day supply of maintenance drugs through the mail. 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 services to obtain an extended supply of maintenance medications. You can use a preferred network retail pharmacy to obtain a 90-day maintenance supply of medications. Please look in the Evidence of Coverage or call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., if you have any questions. Telephone device for the hearing impaired users may call (888) 631-9979.

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. These pharmacies are typically chain pharmacies, and you can find a listing of these in your plan's Provider Directory.

Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. If you go to an out-of-network pharmacy, you may have to pay the full cost of the prescription (rather than paying just your copay or conisurance). 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 plan ID card at any drug store chain listed in your plan's 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, and you can ask us to reimburse you for our share of the cost. Member Services can tell you what information you will need to provide for reimbursement. You may contact Member Services at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., if you have any questions. Telephone device for the hearing impaired users may call (888) 631-9979.

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, or you 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 in your plan's Evidence of Coverage 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.

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.

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 its territories, even for a medical emergency. Peoples Health does provide worldwide coverage for both emergency and urgently needed care up to an annual maximum of $5,000. Please refer to the Evidence of Coverage 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:

• 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.

• 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. The formulary contains the prescription drugs 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. Generally, if you are taking a drug on our formulary that was covere at the beginning of the year, we will not discontinue or reduce coverage of the drug during the year except when a new, less expensive drug becomes available or when new, adverse information about the effectiveness of a drug is released. 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 toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., if you have any questions. Telephone device for the hearing impaired users may call (888) 631-9979.

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 affected members of the change at least 60 days before 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 provide notice to members who take the drug if we remove the drug from our formulary.

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, a non-preferred network pharmacy or an out-of-network pharmacy.

Click here to search for your prescription drugs by your plan.

You will pay a copay/coinsurance for your drugs until your out-of-pocket drugs costs reach $4,550 in 2010. After that, you will generally pay the greater of either $2.50 for generics and $6.30 for all other brand-name drugs, or 5% coinsurance.

Click here to search for Network Pharmacies.

Can the list of network pharmacies change?

Yes. Peoples Health may add or remove pharmacies from our pharmacy listing. For the most up-to-date information about our network pharmacies in your area, please call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., if you have any questions. Telephone device for the hearing impaired users may call (888) 631-9979.  

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.

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 but 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 to request a prior authorization and fax it to (504) 849-6901.

Quantity Limits

For certain drugs, Peoples Health limits the amount of the drug that Peoples Health will cover. For example, Peoples Health provides 9 tablets per prescription for AMERGE^®. This means that your quantity for a one-month or three-month supply of some prescriptions may be different than the standard one-month or three-month supply for other prescriptions.

Step Therapy

In some cases, Peoples Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if drug A and drug B both treat your medical condition, Peoples Health may not cover drug B unless you try drug A first. If drug A does not work for you, Peoples Health will then cover drug B.

30-Day Trial Before 90-Day Prescription Fill

When your doctor writes you a prescription for a 90-day supply of a drug, we ask that you first complete a 30-day supply of the same drug. This is to ensure that you don't have any reactions or adverse affects from the medication. Talk to your doctor about trying each new medication before filling a 90-day supply.

What if my drug is not on the formulary?

Please check our Comprehensive Formulary, or contact Member Services to determine if iyour drug is 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

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year. Please call Member Services 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 a different drug that we cover or requesting a formulary exception.

Please note that our transition policy applies only to those drugs that are Medicare Part D-covered drugs and are bought at a network pharmacy. The transition policy cannot be used to buy a non-Part D-covered drug or a drug from an out-of-network pharmacy, 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 two types of exceptions that you can ask us to make.

Formulary Exceptions
You can ask us to cover your drug even if it not on our formulary. You can also 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.

Tiering Exceptions
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug.

Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.

Generally, Peoples Health will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower-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 or tiering  exception. When you are requesting a formulary or tiering exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. Contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m., to ask us for an initial coverage decision for a formulary exception or a tiering exception.  Telephone device for the hearing impaired users may call (888) 631-9979.

Detailed information about requesting an exception can be found in Chapter 9 of your plan’s Evidence of Coverage.

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.