2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 157 We may make certain changes to the Drug List that are not described above. In these cases, the change will not apply to you if you are taking the drug when the change is made; however, these changes will likely affect you starting January 1 of the next plan year if you stay in the same plan. In general, changes that will not affect you during the current plan year are: · We move your drug into a higher cost-sharing tier. · We put a new restriction on the use of your drug. · We remove your drug from the Drug List. If any of these changes happen for a drug you are taking (except for market withdrawal, a generic drug replacing a brand name drug, or other change noted in the sections above), then the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restrictions to your use of the drug. We will not tell you about these types of changes directly during the current plan year. You will need to check the Drug List for the next plan year (when the list is available during the open enrollment period) to see if there are any changes to the drugs you are taking that will impact you during the next plan year. Section 7 What types of drugs are not covered by the plan? Section 7.1 Types of drugs we do not cover This section tells you what kinds of prescription drugs are “excluded.” This means Medicare does not pay for these drugs. If you get drugs that are excluded, you must pay for them yourself. If you appeal and the requested drug is found not to be excluded under Part D, we will pay for or cover it. (For information about appealing a decision, go to Chapter 9.) Here are four general rules about drugs that Medicare drug plans will not cover under Part D: · Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. · Our plan cannot cover a drug purchased outside the United States or its territories. · Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration. · Coverage for “off-label use” is allowed only when the use is supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System. In addition, by law, the following categories of drugs are not covered by Medicare drug plans: · Non-prescription drugs (also called over-the-counter drugs). · Drugs used to promote fertility. · Drugs used for the relief of cough or cold symptoms. · Drugs used for cosmetic purposes or to promote hair growth.