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Part D Coverage for Members

This page provides general information about how prescription drug coverage works through your Peoples Health plan. Please note that not all Peoples Health plans include prescription drug coverage

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.

Important Message:

You will pay a $0 copay for all Part D covered vaccines, including Shingrix.
You will pay a maximum of $35 for each 1-month supply of Part D select insulin drugs through all coverage stages*

Please also review the introduction to our online formulary for more information about your drug coverage and our Drug List.

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 most 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, visit our Pharmacy Search page or contact member services.

How do I fill a prescription by mail order?

To use a network mail-order pharmacy, you must complete a Mail Service Order Form. Please contact member services to request the form or:

Download mail-order form

You can use a network mail-order pharmacy to fill an extended-day supply of certain medications. An extended-day supply might be 90 days or 100 days, depending on your plan. For more information about mail-order prescription drugs, refer to your plan’s Evidence of Coverage. You must use a network 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?

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.

If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • Prescriptions for a Medical Emergency
    We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care, are included in our Drug List without restrictions, and are not excluded from Medicare Part D coverage.
  • Coverage when traveling or out of the service area
    When traveling within the U.S. you have access to network pharmacies nationwide. Bring your prescriptions and medication with you and be sure to check the provider directory for your travel plans to locate a network pharmacy while traveling. If you are leaving the country, you may be able to obtain a greater day supply to take with you before leaving the country where there are no network pharmacies available.
    • If you are unable to obtain a covered drug in a timely manner within the service area because a network pharmacy that provides 24-hour service is not within reasonable driving distance.
    •  If you are trying to fill a prescription drug not regularly stocked at an accessible network retail or preferred mail-order pharmacy (including high cost and unique drugs).
    •  If you need a prescription while a patient in an emergency department, provider based clinic, outpatient surgery, or other outpatient setting.

In these situations, please check first with member services to see if there is a network pharmacy nearby. You will most likely be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at a network pharmacy.

You can search for network pharmacies on the Pharmacy Search page.

What if I need a prescription because of a medical emergency?

See the question “Can I fill a prescription at an out-of-network pharmacy?” above.

Please note: Our plan cannot cover a drug purchased outside the United States and its territories.

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, our plan cannot cover a drug purchased outside the United States and its territories.

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.

See the question “Can I fill a prescription at an out-of-network pharmacy?” above for more information.

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

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, depending on your plan, on which tier of the Drug List 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 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 (1-800-633-4227), 24 hours a day, seven days a week (TTY users call 1-877-486-2048)
  • Social Security at 1-800-772-1213 (TTY users call 1-800-325-0778)
  • Louisiana Medicaid at 1-888-342-6207 (TTY users call 1-800-220-5404)

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.

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 transition policy is as follows:

What to do if your drugs aren’t on the Drug List (formulary) or are restricted in some way.

Sometimes, you may take a prescription drug that isn’t on your plan’s Drug List or it’s restricted in some way. Whether you’re a new member or a continuing member, there’s a way to get help.

Start by talking to your doctor. Your doctor can help decide if there’s another drug on the Drug List you can switch to. If there isn’t a good alternative drug, you, your representative or your doctor can ask for a formulary exception. If the exception is approved, you can keep getting your current drug for a certain period of time.

Review your Evidence of Coverage (EOC) to find out exactly what your plan covers. If you’re a continuing member, you’ll get an Annual Notice of Changes (ANOC). Review the ANOC carefully to find out if your current drugs will be covered the same way in the upcoming year.

Whether you’re switching drugs or waiting for an exception approval, you may be eligible for a transition supply of your current drug.

  • You must get your 1-month supply, as described in your EOC, during the first 90 days of membership with the plan as a new member OR within the first 90 days of the calendar year if you are a continuing member and your drug has encountered a negative formulary change.
  • You may also be eligible for a one-time, temporary 1-month supply if you qualify for an emergency fill while residing in a long-term care (LTC) facility after the first 90 days as a new member or you have encountered a level of care change.
  • If your doctor writes your prescription for fewer days and the prescription has refills, you may refill the drug until you’ve received at least a 1-month supply, as described in your EOC.

When am I eligible?
The table below covers when you may be eligible for temporary transition supplies of prescription drugs. Be sure to read your plan’s EOC for details.

To read your EOC online, visit our member plan documents and forms | 2023 page. See Chapter 9.

Transition Eligible SituationsTemporary Transition Supply Amount
During the first 90 days of your membership in the plan if you are a new member

During the first 90 days of the calendar year if you were in the plan last year and your drug encountered a negative formulary change
At least a 1-month supply, as described in your plan's EOC
For members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right awayAt least a 31-day supply, as described in your plan's EOC
Members who have unplanned transitions such as hospital discharges (including psychiatric hospitals) or level of care changes (i.e., changing long-term care facilities, exiting and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) at any time during the plan year.At least a 1-month supply, as described in your plan's EOC

If you’re out of medication after receiving a temporary transition supply and you’re working with your prescriber to switch to an alternative drug or request an exception, call the number on your member ID card.

How do I ask for a formulary exception?

Download the 2023 Peoples Health Prescription Drug Transition Policy

 

important links, documents and forms

Links to Plan Documents

Links to Forms

Mail Service Order Form
Download mail-order form

Medicare Prescription Drug Coverage Determination
Download Medicare Part D Coverage Determination Request Form [Updated 3/07/2019] – (for use by members and providers)

You may also file a standard prescription drug coverage determination online by creating or signing in to your account at www.optumrx.com. Your doctor can ask for a prescription drug coverage determination by using the online tool at https://professionals.optumrx.com.

Prescription Drug Reimbursement

Download Prescription Drug Reimbursement Form PDF

Prescription Drug Reimbursement Form – Online Form

 

*Peoples Health Secure Health (HMO-POS D-SNP) and Peoples Health Secure Complete (HMO-POS D-SNP) members won’t pay more than $0 for a one-month supply of each insulin product covered by their plan. Peoples Health Group Medicare (HMO-POS) Office of Group Benefits members won’t pay more than $20 for a one-month supply of each insulin product covered by their plan. Peoples Health Group Medicare (HMO-POS) members won’t pay more than $25 for a one-month supply of each insulin product covered by their plan.

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