Peoples Health Choices Plus (HMO)
Plan Details: Part D Coverage
Part D Coverage
This page provides general information about how your prescription drug coverage works through your Peoples Health plan. The following topics are included:
» How do I fill a prescription at a network pharmacy?
» Can the list of network pharmacies change?
» How do I fill a prescription through mail order?
» Can I fill a prescription at an out-of-network pharmacy?
» What if I need a prescription because of a medical emergency?
» How do I get coverage when I travel or am away from the plan’s service area?
» Are there other times I can get my prescription covered if I go to an out-of-network pharmacy?
» What is the Peoples Health formulary?
» Can the formulary change?
» How much will I pay for drugs covered by the Peoples Health formulary?
» What are generic drugs?
» Are there any other restrictions on coverage?
» What if my drug is not on the formulary?
» What if I have a limited income and resources and need help paying for my prescription drugs?
» What is your transition policy for drugs I am taking that are not on your formulary?
» How do I request an exception to the Peoples Health formulary?
» Important Links, Documents and Forms
If you would like more information about qualifying for Medicare Part D prescription drug coverage, please call Medicare at http://www.medicare.gov.24 hours a day, seven days a week. TTY users should call (877) 486-2048. Or, visit
Click on a question below to reveal the answer.
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. For a listing of our 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 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 refer to your plan’s Evidence of Coverage or call the Member Services department toll-free at, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact Member Services on a weekend or holiday, you may need to leave a message, but your call will be returned within one business day.
We call pharmacies "network pharmacies” when we have made arrangements with them 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 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.
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, search our online listing of network pharmacies on the Pharmacies page. Or, call the Member Services department toll-free at , seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact Member Services on a weekend or holiday, you may need to leave a message, but your call will be returned within one business day.
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 an electronic version. 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. If you order a 90-day supply of a maintenance drug through the mail, you must use the Peoples Health mail-order pharmacy in order for the prescription to be covered by your Peoples Health plan. Prescription drugs that you obtain through any other mail-order pharmacy are not covered.
Please note, a new prescription cannot be filled for a 90-day supply without first filling a 30-day supply of the prescription. You can fill a 30-day supply of a medication at a network retail pharmacy.
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.
We have network pharmacies outside of the service area where you can get your drugs covered as a member of one of our plans. These pharmacies are typically chain pharmacies, and you can find a listing of these in your plan's Provider Directory, in your Physician Team Guide or 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). Before you fill a prescription at an out-of-network pharmacy, please call Member Services to see if there is a network pharmacy available.
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. For example, you can fill prescriptions anywhere in the country with your plan ID card at any pharmacy chain listed in your plan's Provider Directory, in your Physician Team Guide or 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, 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 the Member Services department toll-free at, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact Member Services on a weekend or holiday, you may need to leave a message, but your call will be returned within one business day.
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. 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.
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.
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.
You will be reimbursed 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 (copay or coinsurance).
Note: Peoples Health Group Medicare (HMO-POS) 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. They will still be responsible for their share of the cost (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.
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 plan’s Evidence of Coverage.
To search the Peoples Health formulary, click here.
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 new, 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.
Peoples Health may add or remove drugs from our formulary during the year. If Peoples Health removes drugs from our formulary, adds prior authorization, quantity limits 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 and immediately remove the drug from our formulary.
For updated information about drugs covered by Peoples Health, please click here to use our online prescription drug search or call the Member Services department toll-free at
, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact Member Services on a weekend or holiday, you may need to leave a message, but your call will be returned within one business day.
In the event of a mid-year nonmaintenance formulary change, Peoples Health will update the formulary with an addendum and will notify you in writing by mail.
The amount you pay depends on which tier level your drug falls under on our formulary and whether you fill your prescription at a network pharmacy or an out-of-network pharmacy. It also depends on if you get Extra Help from Medicare to pay for your prescription drug costs. To search for your prescription drugs and to find out what you pay based on the plan you are enrolled in, search for them on our formulary.
You will pay a copay or coinsurance for your drugs until your total drug costs reach $2,970. You then enter the Medicare Part D prescription drug coverage gap. In the coverage gap, you will pay plan copays for preferred generic and nonpreferred generic drugs, and your costs for brand-name drugs will be higher. For more information about the coverage gap, click here. After your total out-of-pocket costs reach $4,750, you will pay the greater of either a $2.65 copay for generics and brand-name drugs treated like generics, and a $6.60 copay for all other drugs, or 5 percent of the cost of the drug.
Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.
If you qualify for Extra Help with your drug costs, your costs for your drugs may be different. Please call Member Services to find out what your costs are.
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.
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
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 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 the Pharmacy Request Form to request a prior authorization and fax it to (504) 849-6901, (225) 346-5700 or (877) 346-4790.
For certain drugs, Peoples Health limits the amount of the drug that Peoples Health 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, Peoples Health provides nine tablets per prescription for AMERGE.
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.
You can find out if your drug has any additional requirements or limits by searching for it on our formulary. You can also ask Peoples Health to make an exception to these restrictions or limits. See How do I request an exception to the Peoples Health formulary? .
Please check our formulary, or contact Member Services to determine if your drug is covered.
If you learn that Peoples Health does not cover your drug, you have two options:
- 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.
- You can also request an exception to the Peoples Health formulary. More details on how to request an exception are listed below.
People with limited income and resources may qualify for Extra Help. If you qualify for Extra Help with your drug costs, your costs for your drugs 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 for Extra Help.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:
- 1-800-MEDICARE ( ). TTY users should call 1-877-486-2048, 24 hours a day, seven days a week;
- The Social Security Office at , between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
- Your state Medicaid office.
If you believe you have qualified for Extra Help and you believe that 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. They will work with you to verify some important information and assist you with obtaining your prescriptions at the appropriate copayment level. You may contact the Member Services department toll-free at , seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact Member Services on a weekend or holiday, you may need to leave a message, but your call will be returned 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, please forward a copy of it to Member Services.
Member Services Department
Three Lakeway Center
3838 N. Causeway Blvd., Ste. 2200
Metairie, LA 70002
- 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, reference the Centers for Medicare & Medicaid Services documents on this topic here.
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 one-time temporary supply for a maximum of one 30-day supply of your drug or multiple prescriptions for your drug that total up to a 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 supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of up to a 31-day supply, or less if your prescription is written for fewer days. If needed, we will cover additional refills during your first 90 days, up to a 98-day supply, in the 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.
Peoples Health provides a transition process for new members who experience a level of care change and are currently on a medication regimen that contains nonformulary drugs. This transition process will occur when the coverage determination processing timeframes are in conflict with the prescribed drug regimen. Peoples Health 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 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 note that our transition policy applies only to Medicare Part D-covered drugs 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.
You can ask Peoples Health 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.
- 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.
- You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our nonpreferred generic drugs tier (tier 2), you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred generic drugs tier (tier 1). If your drug is contained in our nonpreferred brand-name drugs tier (tier 4), you can ask us to lower it at the cost-sharing amount that applies to drugs in the preferred brand-name drugs tier (tier 3) 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 preferred generic tier (tier 1), the preferred brand-name tier (tier 3) or the specialty tier (tier 4).
Generally, Peoples Health will only approve your request for an exception if the alternative drug is included on the plan's formulary, or the lower-tiered 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 us 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.
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. A coverage decision related to drugs is called a coverage determination. To ask us for a coverage determination for a formulary exception or a tiering exception, contact the Member Services department toll-free at
, seven days a week, from 8 a.m. to 8 p.m. TTY users may call 711. If you contact Member Services on a weekend or holiday, you may need to leave a message, but your call will be returned within one business day.
You can also submit your coverage determination request online using the Request for Medicare Prescription Drug Coverage Determination Form.
You may also submit a coverage determination request to us in writing using the Request for Medicare Prescription Drug Coverage Determination Form.
For more information about your Peoples Health prescription drug coverage, please refer to Chapters 5 and 6 of your plans Evidence of Coverage and to your other plan materials. You can access your plans's Evidence of Coverage and other plan documents using the links below.
Links to Plan Documents
» Peoples Health Choices 65 (HMO)
» Peoples Health Choices Plus (HMO)
» Peoples Health Choices Select (HMO)
» Peoples Health Secure Choice (HMO SNP)
» Peoples Health Secure Health (HMO SNP)
» Peoples Health Group Medicare (HMO-POS)
Mail Service Order Form
Download PDF (267 KB)
Pharmacy Request Form
Download PDF (124 KB)
Request for Medicare Prescription Drug Coverage Determination Form
Download PDF (28 KB)
Request for Medicare Prescription Drug Coverage Determination Form
Peoples Health has established a Medication Therapy Management (MTM) program, with no associated fees, designed to ensure optimum therapeutic outcomes for targeted plan members through improved medication use. The program is also designed to reduce the risk of adverse events, including adverse drug interactions, for targeted plan members.
Targeted plan members for the MTM program meet the following eligibility requirements:
- Have three or more of the following chronic diseases: Alzheimer’s disease, chronic heart failure, chronic kidney disease, chronic obstructive pulmonary disease, diabetes or dyslipidemia
- Are taking two or more covered Medicare Part D medications from specific drug classes
- Are likely to incur annual costs for covered Part D medications that exceed the Centers for Medicare & Medicaid Services-defined cost threshold
Members are automatically enrolled in the program but can opt out and re-enroll at any time. Current members of the program must meet eligibility requirements from year to year. Peoples Health may focus on different medications or health conditions for the program each year.
The MTM program has two parts: a targeted medication review and a comprehensive medication review.
Targeted medication reviews are performed quarterly to assess a member’s medication use, monitor whether any unresolved issues need attention and determine if new drug therapy problems have arisen. Targeted reviews focus on drug utilization specific to each disease state for members with Alzheimer’s disease, chronic heart failure, chronic obstructive pulmonary disease, diabetes or dyslipidemia. For members with chronic kidney disease, targeted reviews focus on potentially harmful drug-disease interactions. In addition, targeted reviews assess high-risk medication use in the elderly and identify therapeutic duplications, drug-drug interactions and drug-disease interactions. All members enrolled in the MTM program receive these reviews.
The comprehensive medication review is an optional service offered to eligible members. If a member chooses to participate in this review, a clinical pharmacist contacts the member to discuss all medications he or she takes, including over-the-counter medications, vitamins and herbal supplements, to identify potential medication-related problems and evaluate medication effectiveness. The clinical pharmacist uses the member’s medication information as well as available lab and test results to conduct the review and may discuss review results with the member’s physician. A follow-up letter, medication action plan and personal medication list based on the review are mailed to the member.
Members can also complete a personal medication list on their own by downloading this form. A personal medication list is a helpful tool for keeping track of medications and how to use them the right way.
Personal Medication List
Download PDF (108 KB)
Targeted members may also receive educational materials on applicable chronic conditions as part of the program.
For more information about the MTM program, call Peoples Health toll-free at (800) 631-8443. TTY users should call 711.
The Peoples Health Pharmacy department, in conjunction with the contracted pharmacy benefits manager, maintains management reports and systems to assist in preventing over-utilization and under-utilization of prescribed medications, including, but not limited to, the following:
- Compliance monitoring to improve adherence/persistency with appropriate medication regimens;
- Monitoring procedures to discourage over-utilization through multiple prescribers or multiple pharmacies;
- Quantity versus time edits;
- Early refill edits.
The Pharmacy department maintains methods to ensure cost-effective drug utilization management. This may include, but is not limited to, the following:
- Step therapy;
- Prior authorization;
- Tiered cost-sharing;
- Quantity limits.
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