Transition policy

The Centers for Medicare & Medicaid Services defines an emergency transition supply as a one-time fill of a nonformulary drug, or a drug not on the covered drug list, necessary with respect to current members in the long-term care setting, and will be provided to current long-term care enrollees who enter into a facility from another care setting.

We’ve authorized our claims processor to place a manual override at the point of sale to accommodate a one-time (up to 31 days) fill in this scenario.

The Centers for Medicare & Medicaid Services transition guidance requires that current members affected by a negative change to the covered drug list across contract years must be provided with a transition process consistent with the transition process required for new enrollees.

We allow current members to access transition supplies 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.

Situations may exist in which a member’s transition period may need to be extended, on a case-by-case basis, such as when the member's exception request or appeal hasn’t been processed by the end of the minimum transition period and until such time as a transition has been made.

In these situations, we may extend the member’s transition period in order to provide continued coverage of the transition drug.

For low-income subsidy-eligible beneficiaries, the cost-sharing amount applied doesn’t exceed the statutory maximum copayment amounts. For non-LIS members filling drugs not on our covered drug list, the cost-sharing amount applied during claims adjudication will be consistent with the plan’s approved cost-sharing tiers for drugs not on our covered drug list.

Additionally, for non-LIS members filling drugs on our covered drug list with utilization management requirements, the cost-sharing amount applied during claims adjudication is the cost associated with the plan’s assigned drug list tier.

Per Centers for Medicare & Medicaid Services guidance, members in transition while taking a drug within a protected drug class must be granted continued coverage of therapy for the duration of treatment, up to the full duration of active enrollment in the plan. Prior authorization and step-therapy restrictions, which may apply to new members who have never taken a particular drug, aren’t applied to those members transitioning to the Medicare Part D plan on agents within these key drug classes.

There are six protected classes of medications:

• Antidepressant
• Antipsychotic
• Anticonvulsant
• Antineoplastic, which affect the process of cell division
• Antiretroviral, which doctors use to treat retroviruses
• Immunosuppressant, to prevent organ transplant rejection

Transition fill notification occurs in two ways. We notify the pharmacy at the time of our decision with information that the pharmacist may give to the member regarding the status of the particular drug not on our covered drug list or drug with utilization management. The transition information goes to pharmacies in a retail setting (including home infusion, safety net and IHS / Tribal / Urban Indian Health Program) as well as pharmacies in a long-term care setting.

We also send written notice via U.S. First-Class Mail to a member and the prescriber within three business days of our decision regarding a temporary fill. The notice will include:

• An explanation of the temporary nature of the transition supply the member has received
• Instructions for working with the plan sponsor and the member’s prescriber to identify appropriate therapeutic alternatives that are on the plan’s covered drug list
• An explanation of the member’s right to request an exception to our covered drug list requirements
• A description of the procedures for requesting an exception to our covered drug list requirements

A formulary exception form is available for members, their appointed representatives and doctors. This form may be submitted by mail, fax, the HAP member portal or through email.

Mail

Attn: Pharmacy Care Management
Health Alliance Plan
1414 E. Maple Rd.
Troy, MI 48083

Fax