When this online drug list (formulary) introduction refers to “we,” “us,” or “our,” it means Peoples Health. When it refers to “plan” or “our plan,” it means Peoples Health Choices 65 #14 (HMO), Peoples Health Choices Gold (HMO-POS), Peoples Health Group Medicare (HMO-POS), Peoples Health Secure Health (HMO SNP) or Peoples Health Secure Choice #011 (HMO SNP).
The formulary is a list of the drugs for our plan.
The online formulary is current as of:
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, copayments and coinsurance may change on January 1, 2020, and from time to time during the year.
The online formulary is updated each month.
In the event of a mid-year, nonmaintenance formulary change, we will notify you in writing of certain changes that may affect you.
The online formulary is current as of:
You can use the online formulary to search for covered drugs by name or by therapeutic category (the type of medical conditions that they are used to treat). For example, drugs used to treat a heart condition are in the “Cardiovascular” therapeutic category. You can type in at least three letters of a drug’s name or choose a therapeutic category from the drop-down menu.
You can find out if your drug has any additional requirements or limits by looking at the details for the drug in our online formulary. We also have posted documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information is here.
You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section “How do I request an exception to the Peoples Health formulary?” below for information about how to request an exception.
If you learn that Peoples Health does not cover your drug, you have two options:
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug (for eligible plan members, as named above), 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 (for eligible plan members, as named above) or utilization restriction exception. When you request a formulary, tiering or utilization restriction 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 prescriber’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 a supporting statement from your doctor or other prescriber.
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. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. 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 and 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 while you pursue a formulary exception.
Peoples Health provides a transition process for members who experience a level-of-care change and are currently on a medication regimen that contains non-formulary drugs or formulary drugs with restrictions. This transition process will occur when the coverage determination processing time frames could interrupt the prescribed drug regimen. We will cover up to a 31-day temporary supply of these non-formulary 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 during a skilled nursing facility stay.
If you have questions about Peoples Health, please contact us. Our contact information is here.
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 users should call 1-877-486-2048. Or, visit medicare.gov.