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 for 2021 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.
Frequently Asked Questions
How do I fill a prescription at a network pharmacy?
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 a network mail-order pharmacy, you must complete a Mail Service Order Form. Please contact member services to request the form or:
You can use a network mail-order pharmacy to fill a 90-day supply of certain medications. 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 is not within reasonable driving distance that provides 24-hour service.
- 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 may 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 an 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: We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and its territories, even for a medical emergency.
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.
See the question “Can I fill a prescription at an out-of-network pharmacy?” above for more information.
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?
Most changes in drug coverage happen on January 1. We may need to make changes during the plan year for safety or other reasons that can affect you. We must follow Medicare rules in making these changes.
The drug list may change during the year if your plan:
- Adds new drugs, including generic drugs, as they become available.
- Removes a drug that has been found to be ineffective or unsafe.
- Changes the coverage rules or limits for a drug.
- Moves a drug into a different cost-sharing tier.
If we add new generic drugs: We may immediately remove a brand name drug on our formulary if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our formulary, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.
If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception.
If we remove a drug from the list: Usually, if you’re taking a drug on this drug list that was covered at the beginning of the year, we will not remove or reduce coverage during the year. If you are taking a drug that is removed because a generic version becomes available, we will tell you. If the Food and Drug Administration says a drug you are taking is not effective or is unsafe, we will take it off the drug list right away.
If we change the coverage rules or limits: We’ll tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug.
We’ll tell you about other changes. If a drug you are taking is removed from the drug list during the plan year, we’ll include an update in your Part D Explanation of Benefits (Part D EOB) statement. We’ll tell you about other changes to our drug list at least 30 days before they go into effect or when you request a refill of the drug. If you find out when requesting a refill, you will receive at least a 30-day supply of the drug so you have time to talk with your doctor. To get updated information about the drugs covered by your plan, please contact us.
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:
The plan requires you or your doctor to get prior approval for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.
The plan will cover only a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.
There are also other requirements or limits that may apply. You can find out if your drug has these or any other 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 get 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.
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 2021 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. He/she 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 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 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, 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 https://www.peopleshealth.com/member-plan-documents-and-forms-2021/. 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|
|You have a level of care change at any time during the plan year (for example: going into a long-term care facility from a hospital, going home from a hospital stay, or going home from a long-term care facility stay)||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, contact us using the information on the back of 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 the back of your member ID card.
- You can download the Medicare Part D Coverage Determination Request Form and follow the instructions.
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.
Visit our Coverage Decisions page for information on how to submit an exception (which is a type of coverage decision) for a prescription drug.
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