We maintain a transition process for members whose current drug therapies may not be included in eternalHealth’s Part D plan formulary. This process applies to members in these cases:
- new members following the annual coordinated election period
- newly eligible members transitioning from other coverage at the beginning of a contract year
- transitioning individuals who switch from one plan to another after the beginning of a contract year
- members residing in long-term care (LTC) facilities
- in some cases, current members affected by formulary changes from one contract year to the next
We allow transitions from 90-days from the start of coverage under the plan. The 90-days are calculated from the day you start as an eternalHealth member.
We will extend our transition policy across contract years, should a member enroll in eternalHealth with an effective enrollment date of either November 1 or December 1, and need access to a transition supply.
We may choose to enhance the transition policy to provide coverage beyond these minimum requirements.
Transition Fills for New Members in the Outpatient (Retail) Setting:
We will ensure that in the retail setting, the transition policy provides for at least a one-time temporary fill of at least a month’s supply of medication.
An exception applies if the member presents a prescription written for less than a month’s supply, in which case we allow multiple fills to provide up to a total of a month’s supply of medication.
This transition period is for anytime during the first 90-days of enrollment in eternalHealth, beginning on the member’s effective date of coverage.
If a brand medication is being filled under transition, the previous claim must also be brand. If a generic medication is being filled under transition, the previous claim can be either brand or generic, as based on eternalHealth policies.
Transition Fills for New Members in the LTC Setting:
In the long-term care setting:
The transition policy provides for a one-time temporary fill of at least a month’s supply (unless the member presents with a prescription written for less), which should be dispensed in increments and with multiple fills provided if needed during the first 90-days of enrollment in eternalHealth. This begins on the member’s effective date of coverage with eternalHealth.
After the transition period has expired, the transition policy provides for a 31-day emergency supply of non-formulary Part D drugs (unless the member presents a prescription written for less than 31 days) when an exception or prior authorization is requested.
For members being admitted to or discharged from a LTC facility, early refill edits are not used to limit appropriate and necessary access to their Part D benefit. Members are allowed to access a refill upon admission or discharge.
Emergency Supplies and Level of Care Changes for Current Members:
An Emergency Supply is a one-time fill of a non-formulary drug that is necessary for current members in the LTC setting.
Current members that need a one-time Emergency Fill or that are prescribed a non-formulary drug as a result of a level of care change can be placed in transition.
Transition Across Contract Years:
For current members whose drugs will be affected by negative formulary changes in the upcoming year, we will arrange for a meaningful transition by either:
providing a transition process at the start of the new contract year, or
providing for a transition before the start of the new contract year.
eternalHealth’s transition plan includes an exception process. Our exception process integrates with the overall transition plan.
This exception process complements other processes to support the overall transition plan. The exception process follows the guidelines in the transition plan
We will evaluate an exception request for transitioning members. Our exception evaluation process includes a medical review that considers the clinical aspects of the drug, including any risks involved in switching. This medical review process includes the following steps:
- Outreach is made to the provider to offer therapeutically appropriate formulary alternatives.
- This provides the prescriber an opportunity to switch the member to a covered formulary medication.
- If the prescriber feels the formulary alternatives are not clinically appropriate for the member, they can attest that the alternatives would not be as effective or would cause adverse effects, which would lead to an approval of the requested medication.
The exception policy includes a process for switching new eternalHealth members to therapeutically appropriate formulary alternatives as appropriate.
eternalHealth will make available a Medication Request Form, upon request to members and prescribers through mail, fax, and email.
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