Part D Coverage for Members

This page provides general information about how your prescription drug coverage works through your Peoples Health plan.

If you would like more information about qualifying for Medicare Part D prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

For more information about your Peoples Health prescription drug coverage, please refer to Chapters 5 and 6 of your Evidence of Coverage and to your other plan materials. You can access your Evidence of Coverage and other plan documents under the Links to Plan Documents section of this page.

Frequently Asked Questions

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 pharmacies. Your out-of-pocket costs are lower when you utilize network pharmacies. To search for network pharmacies, visit the Pharmacies page.

If you do not have your ID card with you when you fill a prescription for a drug on our formulary, you may have to pay the full cost of the prescription (rather than paying just your copay or coinsurance). If this happens, you can submit a paper claim to us and ask us to reimburse you for our share of the cost.

To find out how to submit a paper claim, please refer to your plan’s Evidence of Coverage or call member services at 504-849-4685, 225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day.

We call pharmacies “network pharmacies” when we have made arrangements with the pharmacies to provide prescription drugs to our plan members. In some cases, your prescriptions are covered by your Peoples Health plan only if they are filled at a network pharmacy or through our mail-order pharmacy. We will fill prescriptions at out-of-network pharmacies only under certain circumstances. See Can I fill a prescription at an out-of-network pharmacy?

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.

Can the list of network pharmacies change?
Yes. Peoples Health may add or remove pharmacies from our network. For the most up-to-date information about network pharmacies in your area, search our online listing on the Pharmacies page. Or call member services at 504-849-4685, 225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day.
How do I fill a prescription through mail-order?

To utilize the Peoples Health mail-order pharmacy, you must complete a Mail Service Order Form. Please call member services to request the form or download it here. You can use the mail-order service to obtain a 90-day supply of a non controlled maintenance medication. For more information regarding mail-order prescription drugs, refer to your plan’s Evidence of Coverage. You must use the Peoples Health mail-order pharmacy in order for the prescription to be covered by your Peoples Health plan. Prescription drugs obtained through any other mail-order pharmacy are not covered.

You are not required to use the mail-order pharmacy to obtain a 90-day supply of a maintenance medication. You can also use a network retail pharmacy.

Can I fill a prescription at an out-of-network pharmacy?

We have network pharmacies outside of the service area where you can get your drugs covered as a plan member. These pharmacies are typically chain pharmacies. You can search for network pharmacies on the Pharmacies page.

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 coinsurance) then you can ask us to reimburse you for our share of the costs. 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?

We will cover a prescription filled at any pharmacy if the prescription is related to care for a medical emergency or urgently needed care. Our pharmacy network extends beyond our service area and throughout the United States and its territories. For example, you can fill prescriptions anywhere in the country with your plan ID card at any pharmacy chain that is in our pharmacy network. You can search for network pharmacies on the Pharmacies page.

Please note: We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and its territories, even for a medical emergency.

If your medical emergency is outside of our service area and you are unable to locate a network pharmacy, you may have to fill your prescription at an out-of-network pharmacy. In this situation, you may have to pay the full cost (rather than paying just your copay or coinsurance) when you fill the prescription, then you can ask us to reimburse you for our share of the cost. Member Services can tell you what information you need to provide for reimbursement. You may call us at 504-849-4685, 225-346-5704 or 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you call us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day.

How do I get coverage when I travel or am away from the plan’s service area?

You have prescription drug coverage at network and out-of-network pharmacies within the United States and its territories. Your out-of-pocket costs will be lower if you use network pharmacies. However, we cannot pay for any prescriptions filled by pharmacies outside of the United States and its territories, even for a medical emergency.

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 medications you will need. You may be able to order your prescription drugs ahead of time through our mail-order pharmacy or through a network retail pharmacy.

If you are traveling within the United States, but outside of your plan’s service area, 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 may have to pay the full cost (rather than paying just your copay or coinsurance) when you fill your prescription. Then you can ask us to reimburse you for our share of the cost. Remember, we do have network pharmacies outside of the service area — these are typically chain pharmacies. You can search for network pharmacies on the Pharmacies page.

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 arrange for you to get your prescriptions from an out-of-network pharmacy.

Are there other times I can get my prescription covered at 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.

We will reimburse you for a prescription based upon the contracted rate that we would pay for the drug at a network pharmacy (not on the amount paid at an out-of-network pharmacy), less your plan cost-sharing. You will still be responsible for your share of the cost ( your copay or coinsurance).

Note: Peoples Health Group Medicare (HMO-POS) and Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits plan members filling more than a 90-day supply of a prescription will be reimbursed based upon our contracted discount rate that we would pay for the drug at a network pharmacy and not on the amount paid at an out-of-network pharmacy. You will still be responsible for your share of the cost (your copay or coinsurance).

All other limitations, such as those on early refills or quantity limits that would have applied if the prescription was filled at a network pharmacy, apply at out-of-network pharmacies.

What is the Peoples Health formulary?

Our 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 plan’s Evidence of Coverage.

To search the Peoples Health formulary click here.

Can the formulary change?

Yes. Generally, if you are taking a drug on our formulary that was covered at the beginning of the calendar 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 adverse information about the effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits or step therapy restrictions on a drug, or move 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 and immediately remove the drug from our formulary.

For updated information about covered drugs, please click here to use our online prescription drug search or call Member Services at 504-849-4685, 225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day.

In the event of a mid-year nonmaintenance formulary change,we will update the formulary with an addendum and notify you in writing of certain changes that may affect you.

How much will I pay for drugs covered by the Peoples Health formulary?

The amount you pay depends on which formulary tier your drug falls under and whether you fill your prescription at a network pharmacy or an out-of-network pharmacy. It also depends on what level of Extra Help you get from Medicare to pay for your prescription drugs. Search our formulary to find out what you pay based on the plan you are enrolled in.

Your costs also depend on what stage of the prescription drug cycle you are in. For more information, select the Shop Plans link, select your plan year, and choose plan details for your plan from the view all plans page. For more information, refer to Chapter 6 of your Evidence of Coverage.

What are generic drugs?

A generic drug is approved by the Food and Drug Administration as having the same active-ingredient formula as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Peoples Health covers both brand-name drugs and generic 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 or your physician to get prior authorization for certain drugs. This means you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug. Your physician can use the Request for Medicare Prescription Drug Coverage Determination Form to request a prior authorization and fax it to 504-849-6901, 225-346-5700 or 1-877-346-4790.

Quantity Limits:
For certain drugs, Peoples Health limits the amount of the drug that we will cover. Some quantity limits limit the amount of the drug per prescription, and some quantity limits limit the amount of the drug covered for a specific period of time. For example, we provide nine tablets per prescription for 30 days of NARATRIPTAN. This may be in addition to a standard one-month or three-month supply.

Step Therapy:
In some cases, we require 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, we may not cover drug B unless you try drug A first. If drug A does not work for you, we will then cover drug B.

You can find out if your drug has any additional requirements or limits by searching for it on our formulary. You can also ask us to make an exception to these restrictions or limits. See How do I request an exception to the Peoples Health formulary?

What if my drug is not on the formulary?

Please check our formulary, or contact member services to determine if your drug is covered.

If you learn that we do not cover your drug, you have two options:

  1. You may ask member services for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that we cover.
  2. You can ask us to make an exception and cover your drug. For more details on how to request an exception, see How do I request an exception to the Peoples Health formulary?
What if I have a limited income and resources and need help paying for my prescription drugs?

People with limited income and resources may qualify for Extra Help, which helps pay for your prescription drug premiums and costs. If you qualify for help with your drug costs, your costs may be different. Some people automatically qualify for Extra Help and don’t need to apply. Medicare mails a letter to people who automatically qualify.

To see if you qualify, call:

  • 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048, 24 hours a day, seven days a week;
  • Social Security at 1-800-772-1213, between 7 a.m. and 7 p.m., seven days a week; TTY users should call 1-800-325-0778
  • Your state Medicaid office.

If you believe you have qualified for Extra Help and you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level (called best available evidence) or, if you already have the evidence, to provide this evidence to us.

  • If you need assistance obtaining this evidence, contact Member Services. We will work with you to verify some important information and assist you with obtaining your prescriptions at the appropriate cost-sharing level. Call member services at 504-849-4685, 225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day.
  • If you already have your “Supplemental Security Income Notice of Award” letter or your “Medicare Prescription Drug Assistance Important Information” letter from the Social Security Administration (or other evidence that indicates you qualify for Extra Help, such as a copy of your Medicaid card, any documentation from the state that confirms your Medicaid eligibility, a printout from the state’s Medicaid records that confirms your Medicaid eligibility or any other documentation confirming your Medicaid status), please forward a copy of it to us at the address below. There are additional forms of acceptable evidence if you are institutionalized. Contact member services for more information.
  • When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Member Services if you have questions.

For more information about best available evidence, click here to reference the Centers for Medicare & Medicaid Services documents on this topic.

What is your transition policy for drugs I am taking that are not on your formulary?

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 allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (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.

We also provide a transition process for members who experience a level-of-care change and are currently on a medication regimen that contains nonformulary drugs or formulary drugs with restrictions. This transition process will occur when the coverage determination processing timeframes could interrupt the prescribed drug regimen. We will cover up to a 31-day supply of these nonformulary drugs or formulary drugs with restrictions. Level-of-care changes include discharges from hospitals or psychiatric facilities; admissions to or discharges from long-term care facilities; giving up hospice status; or exceeding the limit for days covered by your Peoples Health plan during a skilled nursing facility stay.

If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year.

Please note that our transition policy applies only to Medicare Part D-covered drugs obtained 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?

An exception is a type of coverage decision. Click here for more information about coverage decisions.

You can ask us to make an exception to our coverage rules. There are several types of exceptions you can ask us to make.

  • You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
  • You can also ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit 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 a greater amount.
  • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not in tier 5 (specialty tier). If approved, this would lower the amount you must pay for your drug. If your drug is in tier 4 (nonpreferred brand tier), you can ask us to cover it at the cost-sharing amount that applies to drugs in tier 3 (preferred brand tier). If your drug is in tier 2 (generic tier), you can ask us to cover it at the cost-sharing amount that applies to drugs in tier 1 (preferred generic tier). 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.

Generally, we will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects.

You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization exception.

When you are requesting a formulary or tiering exception, you should submit a statement from your prescriber or 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.

To ask us for an exception, contact Member Services at 504-849-4685, 225-346-5704 or toll-free 1-800-222-8600, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact us on a weekend or holiday, you may need to leave a message, but we will return your call within one business day.

You can also submit your exception request online using the Online Request for Medicare Prescription Drug Coverage Determination Form.

You may also submit a coverage determination request to us in writing by printing the Download Request for Medicare Prescription Drug Coverage Determination Form.

Important Links, Documents and Forms

Links to Plan Documents
Additional Links, Documents and Forms

Mail Service Order Form
Download Mail Service Order Form PDF

Request for Medicare Prescription Drug Coverage Determination Form
Download Request for Medicare Prescription Drug Coverage Determination Form PDF

Request for Medicare Prescription Drug Coverage Determination Form
Online Form – Request for Medicare Prescription Drug Coverage Determination Form

You also have the option to request a coverage determination by completing a form available through Medicare’s website.