Transition fills for Priority Health Medicare members
If you are joining or already belong to a Priority Health Medicare plan, the rules about qualifying for a temporary supply or "transition fill" are a little different for you.
Times you may qualify
When you first join a Priority Health Medicare plan and you are taking a drug that is not on your new plan's approved drug list ("formulary), you have 90 days from the day your plan starts (your "effective date") to get a transition fill.
OR
When your Priority Health Medicare plan is dropping a drug you take or putting prior authorization or step therapy rules on a drug that's on the formulary, you have 90 days from the day your plan starts (your "effective date") to get a transition fill.
OR
When you have Priority Health Medicare and you live in a long-term care facility, you have 93 days from your admission date to the facility to get a transition fill.
If your drug is not on the Approved Drug List or is restricted:
You may be able to:
- Get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your doctor or other health care provider time to change to another drug or to file a request to have Priority Health cover the drug for you.
- Change to another drug.
- Request an exception and ask the plan to cover the drug or remove restrictions from the drug.
Who is eligible for a transition fill
If you are new to your Medicare plan and the drug you are currently taking is not on the Priority Health Medicare formulary, or is on the formulary but is restricted in some way, you are eligible for a temporary supply.
If you are a current member of a Priority Health Medicare plan and the drug you have been taking is no longer on the plan's formulary or the drug you have been taking is now restricted in some way (See Section 5, Chapter 5 of your EOC for more information about restrictions), you are eligible for a temporary supply.
How to order a transition fill
New and current plan members:
- Go to the retail pharmacy with your prescription. You will get a one-time, temporary 31-day fill.
- If your prescription is for less than a 31-day supply, you may be eligible to get more fills to provide you with a 31-day fill anytime during the first 90 days of your enrollment on our plan. This period begins with your effective date of coverage whether you are new or current member.
- We also send your information about your temporary fill. Within three business days of filling your prescription, you will get a written notice explaining a few important things. You will be told that your prescription was temporarily filled. You will be told how to work with us and your provider to find an appropriate alternative on our formulary. And you will get information about your right to request a formulary exception as well as the process for requesting an exception (see below).
Members in long-term care facilities:
- If you are a resident of a long-term care facility, your facility will fill your prescription. You will get a 31-day supply, unless the prescription is written for less.
- You are eligible to get multiple refills as necessary or up to a 93-day supply during the first 90 days you are a member of the plan. This period begins with your effective date of coverage whether you are new or current member.
- We also send your information about your temporary fill. Within three business days of filling your prescription, your will get a written notice explaining a few important things. You will be told that your prescription was temporarily filled. You will be told how to work with us and your doctor or other health care provider to find an appropriate alternative on our formulary. And you will get information about your right to request a formulary exception as well as the process for requesting an exception.
- After this 90-day period ends, our transition policy provides for a 31-day emergency supply while you or your long-term care facility are asking for an exception or a review of prior authorization requirements.
How to change to another drug
During the time when you are getting a temporary supply of a drug, you should talk with your doctor 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. The sections below tell you more about these options.
Start by talking with your doctor. Perhaps there is a different drug covered by the plan that might work just as well for you.
You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you.
How to ask for an exception
You and your doctor or other prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your doctor or other prescriber says that you have medical reasons that justify asking us for an exception, your doctor or other prescriber can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan's formulary (approved drug list). Or you can ask the plan to make an exception and cover the drug without restrictions.
If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will allow you to request a formulary exception in advance for next year. We will tell you about any change in the coverage for your drug for the following year. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for the following year. We will give you an answer to your request for an exception before the change takes effect.
If you and your doctor or other prescriber want to ask for an exception, Chapter 9, Section 6.2 of your EOC tells you what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.
If your drug is excluded from coverage under Medicare Part D:
If a drug is not a covered Medicare Part D drug or is excluded from coverage, it is never covered by Medicare or Priority Health, regardless of medical necessity. However, you can file what is called a "grievance," which is any complaint or dispute, to ask for a "coverage determination."
You may ask for a coverage determination if you believe one of the following situations applies:
- The drug is a covered Part D drug under Section 1860D-2(e)(1) of the Social Security Act or covered under Section 1860D-2(e)(1) for the symptom or health condition it is being prescribed for1; or
- The drug you are requesting is not excluded from coverage under Section 1860D-2(e)(2) of the Social Security Act or being used for a symptom or health condition that isn't excluded under Section 1860D-2(e)(2)2 ; or
- The drug you are requesting is included on the Priority Health Medicare plan formulary as a "supplemental benefit."3
More about how to ask for an exception
If you want Priority Health to make an exception to what drugs are covered for you, you need to follow the steps for requesting a formulary exception, requesting a coverage determination or filing a complaint. You'll find an overview of these steps on this website.
Go to the steps for asking for an exception.
Check your Evidence of Coverage (EOC) booklet
Your EOC has complete information about how your plan works and what you can do to ask for a transition refill or an exception to the Drug List. Choose the EOC for your plan, below, to read more:
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