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Questions? Contact Customer Service at (855) 645-8448

Getting to Know the 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 if a current member is 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 a prescription drug, for Long-Term Care residents. This will give you time to talk to your provider about the change in coverage and other drug options.

New Members are eligible for a Transition fill or Transitional supply in the following situations:

  • 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 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-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 are eligible for a Transition fill or Transitional supply when meeting one requirement listed below or is impacted by a situation listed below.

  • A negative Formulary change occurs when a medication you are taking is removed from the formulary or has an addition of a drug restriction, such as Prior Authorization, Step Therapy, or Quantity Limit or a change in the tier structure.
  • 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 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-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. For 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 Customer Service at (855) 645-8448. (See below for hours of operation.)

In the event that you enroll in our plan while living at home and then become a resident of a LTC facility, you will need to contact Customer Services at (855) 645-8448. This will let Navitus, our prescription benefit management partner, know that you are now the resident of a LTC facility, and we can implement the LTC transition fill for you.

Does the transition policy apply to all drugs?

The transition fill policy does not apply to Medicare Part D excluded drugs, new prescriptions, or to drugs that have been removed from the plan’s formulary due to Food and Drug Administration (FDA) safety recalls. The transition policy does apply to non-formulary drugs and may not apply to drugs with utilization management requirements (drugs with restrictions).

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.

What should the beneficiary or member do?

During the transition period, the new member should use the one-time, transition fill period to work with their doctor to decide whether it’s okay to switch to another drug that we cover on the drug list or the plan’s formulary with no limitations on access, or to request a formulary exception. Please contact Customer Service if your drug is not on our formulary, is subject to certain restrictions such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception. For more detailed information about your Memorial Hermann Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials or contact us directly by calling Customer Service at (855) 645-8448. (See below for hours of operation.)

Contact Customer Service at (855) 645-8448 (TTY/TDD users should call 711.)

Hours of Operation:
October 1 thru March 31 from 8:00 a.m. to 8:00 p.m. CT, 7 days a week
April 1 thru September 30 from 8:00 a.m. to 8:00 p.m. CT, Monday through Friday.

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