Medicare Part D Transition Policy DTransition
User Manual: MedicarePartDTransitionPolicy
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Medicare Part D Transition Policy Overview We want to make the transition into the new benefit year for Medicare Part D members as seamless as possible. That’s why we have policies in place for any prescription drugs that you may be taking. During the first 90 days of membership, we offer a temporary supply of medications to Medicare Part D members who: • Are taking a medication that is not on the formulary or • Are taking a medication that is subject to certain restrictions such as prior approval, quantity limits or step therapy, depending on place of service. Pharmacy Services will offer a temporary one-time fill for a nonformulary drug. The copay will be based on one of our approved formulary tiers. It will also be consistent with cost-sharing charged for non-formulary drugs that are approved under a coverage exception. Copays for members who are eligible for “extra help” will never exceed the copay maximums set by CMS for low-income members. 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 nonformulary drug if you need a refill for the drug during the first 90 days of the new plan year when you use a participating pharmacy or during the first 90 days of the new plan year for a longterm care facility residents. What are the details of the participating pharmacy policy? Provided that the drug is dispensed from a participating pharmacy, Pharmacy Services will offer a one-time fill of up to a 30-day supply of a drug if: • The drug is not a formulary drug. • The drug requires prior approval. • The drug does not meet the required step therapy edits. • The drug is subject to a quantity limit Who is eligible? Newly eligible Medicare Part D participants or those enrolling from another plan during their first 90 days of membership. H6864_MMG12_19 File & Use 12072011 What are the details of the long-term care facility transition policy? Provided that the drug is dispensed from a participating pharmacy, qualified longterm care facility residents will be provided multiple fills of a 31-day supply up to a 98-day supply during the 90 day LTC transition window. If: • The drug is not a formulary drug. • The drug requires prior approval. • The drug does not meet the required step therapy edits. • The drug is subject to a quantity limit If the prescription is written for fewer days and has applicable refills, it will be authorized. Who is eligible? Newly eligible Medicare Part D participants or those enrolling from another plan, or current enrollees for medications utilized by the current enrollees in the previous plan year if that medication has also had a negative formulary change across years during their first 90 days of membership.
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