Transition Process - 2011

How to change to a medicine on our formulary

If your drug is not on our formulary, is subject to certain restrictions, such as prior authorization 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, please contact Member Services.

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 determination) in order to get coverage for the drug

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 new member of the plan and aren't in a long-term care facility, we will cover a temporary 30 day supply of your drug one time only during the first 90 days of your membership in the 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. We will also provide you with the opportunity to request a formulary exception in advance for the following year. For each of the drugs that isn't 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.

Note:  If a member, who is a resident of a long-term care facility and has been enrolled in our Plan for more than 93 days, needs a drug that isn't on our formulary or 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.

Level of Care Change

If you have a change in level of care (setting) you can have up to a one-time 31-day transition supply per drug. Below are examples of level of care changes that apply:

• If you enter a long-term care (LTC) facility from the hospital and you get a discharge list of drugs from the hospital, with very short term planning taken into account (often under 8 hours).
• If you are discharged from a hospital to a home.
• If you leave a skilled nursing facility under a Medicare Part A stay (where payments include all pharmacy charges) and you need to use your Passport Advantage drug list.
• If you leave a long term care facility and return to your house.

If you have more than one level of care change in a month, the pharmacy will have to call Passport Advantage at (866) 533-5490 to request an extension of your long-term care transition supply.

To ask for a temporary supply, call Member Services.
During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered.