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Passport Advantage provides its members with Medicare's new
prescription drug benefit (which is called Medicare Part D).
What You Pay
Passport Advantage members pay co-payments for each prescription
they fill. The Medicare program requires these co-payments.
The co-payments are:
- $1 for each prescription of a generic drug.
- $3 for each prescription of a brand drug.
Once you and the Medicare program (or certain other payers)
have paid $3,600 toward your drug benefit in a calendar year,
you will not have to pay any more co-payments for the rest
of that calendar year.
For more information on the difference between a generic and
a brand drug, see your Passport Advantage Evidence of Coverage
book. Each prescription gives you up to a 30-day supply of medication.
What You Do Not Pay
Passport Advantage members do not pay a monthly plan premium
for any of their benefits (Medicare Parts A, B, or D). The Kentucky
Medicaid program will continue to pay your Medicare Part B monthly
premium.
Except in rare instances, Passport Advantage members do not
pay deductibles or co-insurance amounts for any services, including
prescription drugs. Passport Health Plan or the Kentucky Medicaid
program covers these amounts for Passport Advantage members
who are eligible for Kentucky Medicaid.
Our Rules
These rules apply to all Passport Advantage members, including
members who live in a long term care facility. The Medicare
program has reviewed and approved all of our rules.
Passport Advantage Formulary
In general, you can only use drugs on our formulary,
which is a list of drugs we cover. We also have the following
rules for using drugs on our formulary.
- We will ask you to use the generic version of drug on the
formulary if there is a generic version.
- In some cases, only certain dosages of a drug are on our
formulary.
- In some cases, we will ask you to try using a certain drug,
to treat your condition before we will cover another drug
for that condition.
- We require that your provider ask us for permission (called
"prior authorization") before prescribing certain
drugs on the formulary.
- For most drugs, we allow up to a 30-day supply for each
prescription. However, for certain drugs we only allow a limited
supply each month.
Asking for an Exception or for Prior Authorization
At any time, your provider can ask us for an exception to these
rules or for prior authorization. Read our Exception
and Prior Authorization Policy to learn more. Once your
provider has asked for an exception or for prior authorization,
we will consider what your provider has told us about your medical
condition and why you need the drug. We compare this information
with our policies about when providers should prescribe the
drug.
If you are a new Passport Advantage member and are taking a
drug that is not on our formulary, we will work with you and
your provider to help you change to a covered drug. Also, if
you are a current member and we change our formulary and no
longer cover a drug you are taking, we will help you change
to a covered drug. Read our Transition
Policy for more information.
Passport Advantage Pharmacy Network
Passport Advantage only covers a drug if you fill your prescription
at a pharmacy in our network. However, we will sometimes cover
a prescription if you fill it at a pharmacy that is not in our
network. Read our Out-of-Network
Policy to learn about these situations.
Appeals and Grievances
If you disagree with a decision we made about providing or
paying for any service, including a prescription drug, you may
ask us to review our decision. Asking us to review our decision
is called submitting an "appeal." If you have any
other type of problem with Passport Advantage or our providers,
you may complain to us. Complaining for these reasons is called
submitting a "grievance." Read our Appeals
and Grievances Policy to learn more. At any time, you may
ask us to tell you about how many times our members have asked
for an exception to the formulary or submitted an appeal or
grievance.
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