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.
Members eligible for a temporary supply, must meet one requirement listed below; or be impacted by a situation listed below.
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 Member Services at (844) 860-6750, 24 hours a day, seven days a week. TTY/TDD users should call 711.
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 Member Services at (844) 860-6750, 24 hours a day, seven days a week. TTY/TDD users should call 711. This will let EnvisionRx, 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.
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.