Our Part D transition policy ensures continuous access to medications for both new and existing enrollees affected by formulary changes. It applies to:
- New enrollees joining after the annual election period.
- Medicare enrollees switching from other coverage.
- Individuals changing plans mid-year.
- Current enrollees impacted by formulary changes.
Key Features:
- Temporary Supply: Eligible members can receive a 30-day temporary supply of medications within the first 90 days of coverage. This includes both formulary and non-formulary drugs.
- Multiple Fills: If a prescription is for less than a month, multiple fills are allowed up to a total of one month.
- Coverage Types: Available at all pharmacy types, including retail, home infusion, long-term care, and mail-order.
Implementation:
The program is managed by our Pharmacy Benefit Manager (PBM), which automatically processes and pays eligible claims. Affected enrollees receive written notice within 3 business days after the temporary fill is processed.
Cost-Sharing:
- Low-Income Subsidy (LIS) Enrollees: Charged no more than the statutory maximum copayment for transition supplies.
- Non-LIS Enrollees: Cost-sharing aligns with the formulary exception rates for non-formulary drugs and with standard rates for formulary drugs requiring management.
Steps to Secure Long-Term Access to Your Medications
While using our Transition Fill Program, here's how you can ensure long-term access to your medications:
- Talk to Your Healthcare Provider: Discuss your medication needs with your doctor. They can help you explore formulary alternatives or adjust your treatment plan if necessary.
- Request a Formulary Exception: If your medication is not on the formulary, ask your provider about submitting a formulary exception request. They will need to explain why the medication is medically necessary.
- Consider Switching Medications: If possible, look into switching to a similar medication that is on the formulary, which may have lower costs.
- Review Your Plan's Formulary: Familiarize yourself with the medications covered by your plan to understand your options and any requirements.
This comprehensive program ensures that all enrollees can access necessary medications during transitions while facilitating collaboration with healthcare providers to explore alternatives or request exceptions as needed.