The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered by Piedmont Medicare Advantage. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists and include both brand name and generic drugs. For <2017/2018>, every drug on the Drug List is in one of five cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug:
- <2017/2018>: Preferred generics - Tier 1 (lowest tier), Generics - Tier 2, Preferred brands - Tier 3, Non-preferred drugs - Tier 4, Specialty Tier - Tier 5 (highest tier)
Formulary “Drug List”
2017 Formulary "Drug List" (Printable Format - Updated Monthly)
Formulary Changes (Updated 09/19/2017)>
2018 Formulary "Drug List" (Printable Format - Updated Monthly)
Formulary Changes (Updated xx/xx/xxxx)
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- The prescription is for a medical emergency or urgent care.
- You are unable to get a covered drug in a time of need because there are no 24-hour network pharmacies wthin a reasonable driving distance.
- The prescription is for a drug that is out-of-stock at an accessible network retail or mail service pharmacy (including high-cost and unique drugs).
- If you are evacuated or otherwise displaced from your home because of a Federal disaster or other public health emergency declaration.
- Illness while traveling outside of the plan’s service area where there is no network pharmacy. 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 pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Piedmont Select Medicare Option One, Piedmont Select Medicare Option Two or Piedmont Select Medicare Option Three. For a description of the prescription drug benefits, please refer to the Summary of Benefits “Outpatient Prescription Drugs” section.
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. This is also known as the transition policy. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To get the most up-to-date information call Caremark Customer Care at one of the telephone numbers listed below, 24 hours a day, seven days a week.
Caremark Customer Care toll-free number:
TTY users should call 7-1-1
Piedmont Medicare Advantage is a PPO plan with a Medicare contract. Enrollment in Piedmont Medicare Advantage depends on contract renewal. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
H1659_Web2018 Approved 10112017
Last Updated: 10/16/2017