Part D Prescription Drug Coverage
Drug Coverage Is Included With Most Peoples Health Plans
Most Peoples Health plans include Medicare Part D prescription drug coverage.
Original Medicare does not include Part D prescription drug coverage. To get it, you need to enroll in a prescription drug plan. If you don’t get drug coverage when you are first eligible, you may face a penalty if you want to sign up for it later.
One option for getting Part D coverage is a “stand-alone” prescription drug plan. This type of plan only covers prescription drugs – it does not cover any medical care.
Another option is to choose a Medicare Advantage plan that includes prescription drug coverage. With most Peoples Health plans, you don’t have to pay for a separate prescription plan because Part D drug coverage is included.
A word of warning: If you are in a Medicare Advantage plan with prescription drug coverage and you sign up for a separate Part D plan, you will be disenrolled from your Medicare Advantage plan.
You cannot be enrolled in two plans at once that both offer Part D prescription drug coverage.
The Part D Coverage Gap – Or “Donut Hole”
The “doughnut hole” is another name for the Part D coverage gap. It’s a period where you’re responsible for a larger percentage of the cost of your drugs. The amounts may change from year to year.
In 2024, the gap starts after you and your plan have spent $5,030 and lasts until your out-of-pocket costs reach $8,000.
Peoples Health covers all generic drugs that are on tier 1 and tier 2 of our drug list through the coverage gap.
This means your out-of-pocket costs for tier 1 and 2 generic drugs will not increase when you are in the gap. Members of Peoples Health special needs plans and members of Peoples Health Group Medicare plans are covered for all drugs during the gap.
Extra Help
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you are eligible, you can contact the agencies below.
Medicare
1-800-MEDICARE (1-800-633-4227)
TTY users should call 1-877-486-2048
Social Security Administration
1-800-772-1213
TTY users should call 1-800-325-0778
Louisiana Medicaid
1-888-342-6207
TTY users should call 1-800-220-5404
Or call Peoples Health, and we will help you find out if you qualify for extra help.
Part D Transition Policy
What is your transition policy for drugs I am taking that are not on your formulary or that have restrictions?
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 page. See Chapter 9.
| Transition Eligible Situations | Temporary 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 away | At 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?
- Your doctor can ask for a formulary exception by using the online tool at https://professionals.optumrx.com. This is recommended for a faster response.
- You can contact us using the information on your member ID card.
- You can download the Medicare Part D Coverage Determination Request Form and follow the instructions.
Download the 2024 Peoples Health Prescription Drug Transition Policy