SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal Have you read Section 4 of this chapter (A guide to of coverage decisions “the basics” If not, you may want to read it before you start this section. and appeals)? Section 6.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our To be covered, the drug must be used for List of Covered Drugs (Formulary). plan’s a medically accepted indication. (A accepted is a use of the drug that is “medically indication” either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.) This section is about your Part D drugs only. To keep things simple, we generally say in the rest of this section, instead of repeating outpatient prescription “drug” “covered or D every time. drug” “Part drug” For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 5 (Using our plan’s and Chapter 6 (What coverage for your Part D prescription drugs) you pay for your Part D prescription drugs). Part D coverage decisions and appeals As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Legal Terms An initial coverage decision about your Part D drugs is called a “coverage determination.” Here are examples of coverage decisions you ask us to make about your Part D drugs: You ask us to make an exception, including: Asking us to cover a Part D drug that is not on the List of Covered Drugs plan’s (Formulary) Asking us to waive a restriction on the coverage for a drug (such as limits plan’s on the amount of the drug you can get)
SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section. Section 6.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan’s List of Covered Drugs (Formulary). To be covered, the drug must be used for a medically accepted indication. (A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.) This section is about your Part D drugs only. To keep things simple, we generally say “drug” in the rest of this section, instead of repeating “covered outpatient prescription drug” or “Part D drug” every time. For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 5 (Using our plan’s coverage for your Part D prescription drugs) and Chapter 6 (What you pay for your Part D prescription drugs). Part D coverage decisions and appeals As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Legal Terms An initial coverage decision about your Part D drugs is called a “coverage determination.” Here are examples of coverage decisions you ask us to make about your Part D drugs: You ask us to make an exception, including: Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary) Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
H4093_ISNP_HMO_NONPOS_Model_wRx_v2-PA_EOC.docx