2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 149 you can get your prescriptions filled as a member of our plan. Please check first with Customer Service to see if there is a network pharmacy nearby. You will most likely 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 in-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 pharmacy 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 for the country where there are no network pharmacies available. · For more information about prescriptions while you travel, refer to the Medical Benefits Chart in Chapter 4, Section 2.1. · If you are unable to obtain a covered drug in a timely manner within the service area because a network pharmacy that provides 24-hour service is not within reasonable driving distance. · 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. How do you ask for reimbursement from the plan? If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal cost share) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2 explains how to ask the plan to pay you back.) Section 3 Your drugs need to be on the plan’s Drug List Section 3.1 The Drug List tells which Part D drugs are covered The plan has a “List of Covered Drugs (Formulary).” In this Evidence of Coverage, we call it the Drug List for short. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list meets Medicare’s requirements and has been approved by Medicare. The drugs on the Drug List are only those covered under Medicare Part D. We will generally cover a drug on the plan’s Drug List as long as you follow the other coverage rules explained in this chapter and the use of the drug is a medically accepted indication. A “medically accepted indication” is a use of the drug that is either: