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We provide a transition process consistent with 42 CFR §423.120(b)(3), which deals with access to covered prescription drugs under Medicare Part D.
The process includes a written description of how enrollees whose current drug therapies may not be included in the HAP covered drug list, also known as a formulary, may receive a temporary supply of a nonformulary drug, as well as Part D drugs that are on the formulary but require prior authorization, step therapy or are subject to quantity limits under the HAP Senior Plus utilization management rules.
A meaningful transition period allows sufficient time for members to work with their health care provider to select an appropriate formulary alternative or to request a formulary exception based on medical necessity.
The transition policy applies to:
The following information applies to members who make use of our transition policy:
The outpatient pharmacy setting includes retail, home infusion and safety net and Indian Health Service/Tribal/Urban Indian Health pharmacies. A temporary, 30-day supply (unless the prescription is written for less than a 30-day supply) of drugs not included on our list of covered drugs will be provided anytime during the 90-day transition period.
Multiple fills of a temporary, 31-day supply (unless the prescription is written for less than a 31-day supply) will be provided during the 90-day transition period. HAP Senior Plus honors multiple fills of Part D drugs not included on our covered drug list during the entire length of the 90-day transition period for up to a 98-day supply.
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:
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 Indian Tribal Union) as well as pharmacies in a long-term care setting.
We also send written notice via U.S. First-Class Mail to a member within three business days of our decision regarding a temporary fill. The notice will include:
A formulary exception form is available for members, their appointed representatives and doctors. This form may be submitted by mail, fax or through email.
Copyright © 2017 HAP
2017 Health Alliance Plan of Michigan
Y0076_ALL 2018067 2018 WEB 10.1
CMS Approved: 10/24/2017
Last Update 10/1/2017
HAP Senior Plus HMO, HMO-POS, and PPO are health plans with a Medicare contract. Enrollment in these plans depends on contract renewal. HAP Senior Plus PPO is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP. Alliance Medicare Supplement is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
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