EASY CHOICE HEALTH PLAN (HMO)'S TRANSITION PROCESS
The Centers for Medicare are Medicaid Services (CMS) requires all Medicare Part D health plans to have a Transition program the provides new Part D members with access to covered Part D drugs.
The purpose of the program is to prevent disruption of therapy for new members in our Plan that are established on medications that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to an appropriate drug that we cover or request a formulary exception (which is a type of coverage in order to get coverage for the drug).
Please contact Customer Services if your drug is not on our formulary, is subject to certain restrictions, such as prior or step therapy or will no longer be on our formulary next year, and you need help switching to an appropriate drug that we cover or requesting a formulary exception.
During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year provide you with the opportunity to request a formulary exception in advance for the following year.
For each of the drugs that is not on our formulary or that has coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is otherwise a “Part D drug”). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan, when that member is a resident of a long-term-care facility. If a new member, who is a resident of a long-term-care facility and has been enrolled in our Plan for more than 90 days, needs a drug that is not on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.
If you are a current member transitioning to a different level of care, you may be prescribed medications not on our formulary. In these instances, you need to talk to your doctor about the appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking to your doctor to determine your course of action, you are eligible to receive a 31-day transition supply of the drug since you are a transitioning to a different level of care.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy cannot be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access.