Prescription Drug Benefits
When you join Simply Healthcare Medicare Advantage a Health Maintenance Organization (HMO) that offers Medicare prescription drug coverage, you must get your prescription drugs (Part D) through the plan's network pharmacies.
What are Medicare Part D Covered Drugs?
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.
A formulary is a list of covered drugs selected by Simply Healthcare in consultation with a team of health care providers. It represents the prescription therapies believed to be a necessary part of a quality treatment program. Simply Healthcare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage (EOC) (see your county page for your EOC).
Simply Healthcare covers both brand name drugs and generic drugs.
- Generic drugs have the same active-ingredient formula as a brand name drug.
- Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
Generally if a drug is on our formulary at the beginning of the year, we will not discontinue or reduce coverage of the drug during coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.
Other types changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
To find out more information on covered drugs by Simply Healthcare, click on the link below.Find Your Covered Drugs
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.
Prescription Information Tool
CarelonRx is Simply Healthcare's prescription information tool. As our member, you can use the CarelonRx's tool below to view your medication history, locate participating pharmacies near you, read important information about prescription drugs, verify your prescription drug benefit information, and keep a journal of medications. Your prescription information is available real-time providing the most accurate information possible to assist you with your prescription benefit needs.
For more information on how to register, click on the link below.
Y0114_20_118627_U CMS Accepted 12/30/2019