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Transition Policy

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 a prescription, for Long-Term Care residents.

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.

Members eligible for a temporary supply, must meet one requirement listed below; or be 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 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:

  • 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 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.

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.