For Medicare Advantage members who may be affected by formulary changes or members who are new to Central Health Plan, we want to make sure your transition is as seamless as possible. That’s why we have policies in place for any prescription medications you are taking.
Central Health Plan’s goal is to make changes that occur each new benefit year as seamless as possible. Our transition policy meets the immediate needs of our members and allows you time to work with your provider to switch to another medication that is on the covered drug list (formulary) to treat your condition or ask for an exception.
During the first 90 days of membership, we offer a temporary supply of medication to:
Central Health Plan will ensure system capabilities are in place to allow a temporary supply of Part D medications that are not on our formulary and Part D medications that are on our formulary, but may require:
Prior authorization (PA)- These medications need to be approved in advance before we cover them.
Step Therapy (ST)- These medications require your provider to first try certain medications to treat a medical condition before we will cover another medication.
Quantity limits (QL)- These medications have limits for a certain amount over a certain time. If your provider thinks you need to receive more, you or your provider may ask for an exception.
In a non-LTC setting, members are allowed a one-time, temporary fill of at least a 30-day supply of medication anytime during the first 90 days of enrollment in a plan, beginning on the member’s effective date of coverage.
If a member is in an LTC setting, the transition process will include the following:
Central Health Plan will provide a process for members to receive necessary Part D medications via an extension of the transition period, on a case-by-case basis, to the extent that their exception requests or appeals have not been processed by the end of the minimum transaction period and until such time as a transition has been made (either through a switch to an appropriate formulary medication or a decision on an exception request).
The cost share for the medication received through transition will be based one of Central Health Plan’s approved formulary tiers.
The cost-share tier, for a temporary supply of medication, provided through the transition process will not exceed the statutory maximum co-payment amounts for low-income subsidy (LIS) eligible members.
Central Health Plan will send written notification, within three business days of adjudication of a temporary transition fill. The notice will include:
To ask for a temporary supply, call Express Scripts.
Member Services Department Contact Information
Calls to these numbers are free.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
Our business hours are 7 days a week
from 8:00am to 8:00pm (PT).
Our business hours are 7 days a week from 8:00am to 8:00pm (PT).
PO Box 14244, Orange, CA 92863