This page provides general information about how 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 www.medicare.gov.
For more information about your Peoples Health prescription drug coverage, please refer to Chapters 5 and 6 of your plan’s Evidence of Coverage and to your other plan materials. You can find your Evidence of Coverage and other plan documents under the Important Links, Documents and Forms 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 use network pharmacies. To search for network pharmacies, visit the Pharmacy Search 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 contact member services.
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?
How do I fill a prescription by mail order?
To use the Peoples Health mail order pharmacy, you must complete a Mail Service Order Form. Please contact member services to request the form or:
You can use the mail order pharmacy to fill a 90-day supply of certain medications; depending on your plan, some prescriptions may be available for a 30-day supply by mail order. For more information about mail order prescription drugs, refer to your plan’s Evidence of Coverage. You must use the Peoples Health mail order pharmacy for the prescription to be covered by your Peoples Health plan. Prescription drugs filled through any other mail order pharmacy are not covered.
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 Pharmacy Search 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 contact 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 Pharmacy Search 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.
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 fill 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, and a network pharmacy is not available, 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. 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 using our Pharmacy Search.
Before you fill your prescription at an out-of-network pharmacy, contact 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 health care 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 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.
Use our Medication Search to find drugs on the Peoples Health formulary.
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 generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. 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 may make changes to our formulary during the year.
Drugs removed from the market. 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.
Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. 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 tier, we must notify affected members of the change at least 30 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 30-day supply of the drug.
In the event of a mid-year nonmaintenance formulary change, we will 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 your plan. The amount will be based either on whether the drug is a brand drug or a generic drug, or on which tier of the formulary the drug is in. It will also depend on whether you fill your prescription at a network pharmacy or an out-of-network pharmacy. If you receive Extra Help from Medicare to pay for your prescription drugs, this will also affect what you pay.
Your costs also depend on what stage of the prescription drug cycle you are in. For more information, see Chapter 6 of your plan’s Evidence of Coverage.
What are generic drugs?
A generic drug is approved by the Food and Drug Administration as having the same active ingredient 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:
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 prior authorization.
For certain drugs, Peoples Health limits the amount of the drug that we will cover. For example, we provide 12 tablets per prescription for 30 days of naratriptan. This may be in addition to a standard one-month or three-month supply.
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 using our Medication Search. 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?
If you learn that we do not cover your drug, you have two options:
- 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.
- 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 your prescription drug premiums and costs. 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 (
- Social Security at
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.
- 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 send a copy of it to us. 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 or that have restrictions?
Our 2019 transition policy is as follows:
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 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 when you go to a network pharmacy. 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.
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 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 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?
For those plans that have a formulary with tiers: 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.
- For those plans that have a formulary with tiers: 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.
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 an 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 the 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 the supporting statement from your doctor or other prescriber.
To ask us for an exception, contact member services.
You can also submit your exception request using our online Request for Medicare Prescription Drug Coverage Determination Form.
You may also submit a coverage determination request to us in writing by printing the Request for Medicare Prescription Drug Coverage Determination Form.
Important Links, Documents and Forms
Links to Plan Documents
Additional Links, Documents and Forms
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
Request for Medicare Prescription Drug Coverage Determination Form – Online Form