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General Transition Notice

What if my current prescription drugs are not on the formulary or are limited on the formulary?


New Members

As a new member in our plan, you may currently be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your 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 with your doctor to determine your course of action, you may be eligible to receive an initial 30 days transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Current enrollees who are affected by formulary changes from one contract year to the next

For current enrollees whose drugs will be affected by negative formulary changes in the upcoming year, Central Health Medicare Plan will effectuate a meaningful transition by providing a transition process at the start of the new contract year by allowing current members to access transition supplies at the point-of-sale when their claims history from the previous calendar year contains an approved claim for the same drug that the member is attempting to fill through transition and the drug is considered a negative change from one plan year to the next.

Current Members with a change in their level of care

Central Health Medicare Plan acknowledges that you may experience a change in the level of care you receive and/or may be required to transition from one facility or treatment site to another. Exceptions are available to you if you experience a change in the level of care you are receiving. Examples of when you would be eligible for a one-time temporary fill exception for changes in your level of care are:

  1. You have been discharged from the hospital and have been provided a discharge list of medications based upon the formulary of the hospital; 
  2. Your have completed your Part A stay at a skilled nursing facility (where payments included all pharmacy charges) and have reverted back to your Part D plan formulary; 
  3. You have discontinued Hospice Status and have reverted back to standard Medicare Part A and B benefits; or
  4. You have been discharged from a Chronic Psychiatric Hospital with a medication regimen that is highly individualized.

If you experience a change in the level of care you are receiving, Central Health Medicare Plan will cover a temporary 30-day supply (unless you have a prescription written for fewer days) regardless of whether or not you are not within your first ninety (90) days of program enrollment.

If you have any questions about our transition policy or need help asking for a formulary exception, call Member Services at 1-866-314-2427 or TTY/TDD 1-888-205-7671.



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