Prescription Drug Benefits

Medicare Part D covered drugs are available only by prescription, approved by the Food and Drug Administration (FDA) and used and sold in the United States. These medications are listed on the plan’s approved list of covered drugs.

Medicare covered Part D drugs include:

• Prescription drugs
• Biological products
• Insulin as defined by the Centers for Medicare and Medicaid Services (CMS)
• Certain vaccines
• Medical supplies associated with the injection of insulin such as syringes, needles, alcohol swabs, and gauze

What are Medicare Part B Covered Drugs?

Medicare Part B covered drugs include a limited number of prescription drugs such as those you get in a hospital outpatient department under certain circumstances, injected drugs you get in a doctor's office, certain oral cancer drugs, and drugs used with some types of durable medical equipment (like a nebulizer or infusion pump).

Medicare Part B drugs include, but are not limited to, the following types of drugs:

• Durable Medical Equipment (DME) Supply Drugs such as: nebulizers, external or implantable pumps
• Hemophilia clotting factors: Self-administered clotting factors if you have hemophilia
• Immunosuppressive Drugs: Immunosuppressive drug therapy a beneficiary has received from a Medicare-covered organ transplant
• Oral Anti-Cancer and Anti-Nausea Drugs
• Pneumococcal and Hepatitis B vaccines and administration

For additional information on Medicare Part B covered drugs, refer to your Summary of Benefits or Evidence of Coverage (EOC) (see your county page for your EOC).

Part B Drugs may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Please contact the plan for additional information.

Pharmacy Network

PART D COVERAGE OUTSIDE OF THE SERVICE AREA

Simply Healthcare offers national in-network prescription drug coverage. This includes the 50 States and the District of Columbia.

This means that you will pay the same cost sharing amount for your prescription drugs if you get them at an in-network pharmacy outside the plan’s service area (for instance when you travel).

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.

If you are traveling within the U.S. and become ill, lose or run out of your prescription drugs, the plan will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules. Prior to filling your prescription at an out-of-network pharmacy, call the Member Services Department 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, the Member Services Department may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

OUT OF NETWORK PHARMACIES

In special circumstances, for instance, illness while traveling outside the plan’s service area where there is no network pharmacy, drugs listed on the plan's formulary may be covered. You may have to pay more than your normal cost sharing amount if you get your drugs at an out of network pharmacy. In addition, you will likely have to pay the full amount for the drug at the pharmacy and submit documentation to receive reimbursement from Simply Healthcare.

• Direct Member Reimbursement Form
• Direct Member Reimbursement Form - Spanish