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Transition Policy

What if my drug is not covered?

As a new member in our plan, you may be taking medications that are not on our drug list (also called a formulary), or medications that are on our formulary, but require prior authorization, step therapy or quantity limit restrictions under our utilization management rules. If a new member is within their first 90 days of enrollment, or for current members in the first 90 days of the calendar year, Memorial Hermann Advantage can offer a temporary 30 day supply or a 31 day supply for Long-Term Care residents, for a prescription drug. This will give you time to talk to your provider about the change in coverage and other drug options.

Members eligible for a temporary supply, must meet one requirements listed below; or impacted by a situation listed below.

  • A negative formulary change that impacts a drug you are currently taking.
  • Added Restrictions to a drug you are currently taking.

New Members:

  • New Members who reside in a long-term care (LTC) facility: A temporary supply of your drug is provided if you are newly enrolled. The total supply will be for a maximum of a 93-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 93-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
  • New Members who are not in a long-term care (LTC) facility: A temporary supply of your drug is provided if you are newly enrolled. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for less than a 30-day supply, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication.

Current Members:

  • Current members who were in the plan last year and reside in a long-term care (LTC) facility: A temporary supply of your drug is provided during the first 90 days of the calendar year if you are an existing member. The total supply will be for a maximum of a 93-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 93-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
  • Current members who were in the plan last year and are not in a long-term care (LTC) facility: A temporary supply of your drug is provided during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for less than a 30-day supply, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication.

All qualified transition fills for new members, either in the retail setting or in the long-term care (LTC) setting, will process automatically. New and current members that require a transition fill, such as experiencing a level of care change beyond your first 90 days as a member, you or your pharmacist should contact Member Services at (844) 860-6750 (HMO) or (844) 782-7672 (PPO), seven (7) days a week, 24 hours a day. TTY/TDD users should call 711.

In the event that you enroll in our plan while living at home and then become the resident of an LTC facility, you need to contact Member Services at (844) 860-6750 (HMO) or (844) 782-7672 (PPO), seven (7) days a week, 24 hours a day. TTY/TDD users should call 711. This will let Envision, our prescription benefit management partner, know that you are now the resident of an LTC facility, and we can implement the LTC transition fill for you.

How will I be notified?

We will send you written notice via U.S. First-Class Mail within three business days of receiving your transition fill transaction from the pharmacy. This notice will contain an explanation of the temporary nature of that prescription fill; instructions on how to identify an appropriate therapeutic alternative that is on our formulary; an explanation of your right to request a formulary exception; and the procedure for requesting a formulary exception.

For more detailed information, you may refer to your Evidence of Coverage, Chapter 5.