Transition of Care Policy

Part D Transition of Care Policy

What if my current prescription drugs are not on the formulary or are included on the formulary but are subject to certain limits?

What is a Transition of Care Policy and How Does it work?

Medica's transition of care policy allows members to get coverage for medications that aren't on our formulary or have limitations such as:

• Step therapy required
• Quantity limits
• Requiring prior authorization when new to our plan
• Affected by changes across calendar years
• Other significant health events such as being admitted to a long-term care facility

Our transition of care policy doesn't provide an automatic lower tier copayment for your medications if they're covered under the upcoming year's formulary but at a higher tier level. You or your prescriber will need to submit a coverage determination request for formulary coverage and exceptions to a formulary tier placement.

New Members

As a new member in our plan, you may be taking Medicare Part D-eligible drugs. For each of these drugs not on our formulary or for situations where your ability to get the drugs is limited, we'll cover a one-time, temporary supply of at least one month (unless you have a prescription written for fewer days) during the first 90 days of your enrollment in the plan. If the prescription is written for less than a month's supply, you'll be allowed multiple fills to provide at least a total of a month's supply of medication. Your cost-sharing for this transition fill will be the same, as there was already a coverage determination or formulary exception in place for the medication.

You and your prescriber will be sent a written letter within three business days once your pharmacy receives an approved claim for a medication under the transition supply policy. When you get the transition supply letter, you and your prescriber should discuss whether there are appropriate alternative therapies on our formulary. If there are none, you or your prescriber can request a formulary exception. If the exception is approved, we'll send you written notice. You can then obtain the drug for a specified period of time.

If you're a resident of a long-term care facility at the time of your enrollment, we'll cover prescription fills of eligible drugs at the point-of-sale to provide at least a one-month transition supply during the first 90 days you are a member of our plan (unless you have a prescription for fewer days). If you're past the first 90 days of membership in our plan and need a drug that's not on our formulary or which is subject to certain limits, we'll cover at least a 31-day emergency supply of it (unless you have a prescription for fewer days) while you pursue a formulary exception.

Long-Term Care Admissions

If you're admitted to a long-term care facility at any time during your membership, we'll cover prescription fills of eligible drugs at the point-of-sale to provide at least a one-month transition supply during the first 90 days after you've been admitted to the facility as a member of our plan. If you need a drug that's not on our formulary or which is subject to certain limits, you're eligible for at least a 31-day emergency supply of it (unless you have a prescription for fewer days) while you pursue a formulary exception. If you're admitted or discharged from a long-term care facility during the plan year, we'll allow an early refill of your eligible drugs to ensure access to your drugs.

Continuing Members

As a continuing member in our plan from one calendar year to the next, you'll receive your Annual Notice of Changes (ANOC) by September 30 of each year. You may notice that a formulary medication you currently take is either not on the upcoming year's formulary or that coverage for it is limited in the upcoming year. For each of your drugs affected by a negative change as a result of the updated formulary, we'll cover a one-time, temporary supply of at least a one-month supply (unless you have a prescription written for fewer days) during the first 90 days of the calendar year. If the prescription is written for less than a month's supply, you'll be allowed multiple prescription fills to provide at least a total of a month's supply of medication. Your cost-sharing for this transition fill will be the same, as there was already a coverage determination or formulary exception in place for the medication. You and your prescriber will be sent a written letter within three business days of an approved claim filled under the transition supply policy. When you get a transition supply letter, you and your prescriber should discuss appropriate alternative therapies based on our formulary. If there are none, you or your prescriber can request a formulary exception. If the exception is approved, we'll send you written notice, and you can obtain the drug for a specified period of time.

Are all drugs eligible for Transition of Care Supplies?

A drug is eligible for the transition of care policy only if it's a Medicare Part D-approved drug. Part D drugs include medications not on our formulary or medications that are on our formulary but with a restriction such as quantity limits, step therapy, or requiring prior authorization. Medications that are specifically excluded from Medicare Part D and not covered under this transition of care policy include, but are not limited to:

• Over-the-counter medications
• Drugs for treating erectile dysfunction
• Drugs for cosmetic indications
• Part B drugs, etc.

Drugs that require a Medicare benefit determination to ensure they're applied to the correct part of Medicare (for example, Part B or Part D) or drugs with FDA safety-related dosing quantity limits also aren't covered under this transition of care policy.

Have questions?

If you have any questions about Medica's Part D transition of care policy or need help asking for a coverage determination or formulary exception, please call customer service: