2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 153 plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called “step therapy.” Quantity limits For certain drugs, we limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. Section 5 What if one of your drugs is not covered in the way you’d like it to be covered? Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered There are situations where there is a prescription drug you are taking, or one that you and your provider think you should be taking, that is not on our drug list (formulary) or is on our formulary with restrictions. For example: · The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered. · The drug is covered, but there are extra rules or restrictions on coverage for that drug, as explained in Section 4. · The drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more expensive than you think it should be. · There are things you can do if your drug is not covered in the way that you’d like it to be covered. If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn what you can do. · If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to Section 5.3 to learn what you can do. Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? If your drug is not on the Drug List or is restricted, here are options: · You may be able to get a temporary supply of the drug. · You can change to another drug. · You can request an exception and ask the plan to cover the drug or remove restrictions from the drug. You may be able to get a temporary supply Under certain circumstances, the plan must provide a temporary supply of a drug that you are already taking. This temporary supply gives you time to talk with your provider about the change in coverage and decide what to do. To be eligible for a temporary supply, the drug you have been taking must no longer be on the plan’s Drug List OR is now restricted in some way.