Pharmacy Transition Policy and Process

Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, IEHP DualChoice Cal MediConnect Plan (Medicare - Medicaid Plan) might make many kinds of changes to the Formulary. For example, the plan might:

  • Add or remove drugs from the Formulary. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
  • Move a drug to a higher or lower cost-sharing tier.
  • Add or remove a restriction on coverage for a drug.
  • Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s Formulary.

If any of the following types of changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in the plan:

  • If we move your drug into a higher cost-sharing tier.
  • If we put a new restriction on your use of the drug.
  • If we remove your drug from the Formulary, but not because of a sudden recall or because a new generic drug has replaced it.

If any of these changes happen for a drug you are taking, then the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes will affect you.

In some cases, you will be affected by the coverage change before January 1:

Some changes to the Drug List will happen immediately. For example:

  • A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower.

When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.

    • We may not tell you before we make this change, but we will send you information about the specific change or changes we made.
    • You or your provider can ask for an “exception” from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions.
  • A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Your provider will also know about this change. He or she can work with you to find another drug for your condition.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

  • The FDA provides new guidance or there are new clinical guidelines about a drug.
  • We add a generic drug that is not new to the market and
    • Replace a brand name drug currently on the Drug List or
    • Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

  • Get a 31-day supply of the drug before the change to the Drug List is made, or
  • Ask for an exception from these changes. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]).
  • Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. We will let you know of this change right away.
  • Your doctor will also know about this change, and can work with you to find another drug for your condition.
 What if you are in a hospital or skilled nursing facility for a stay covered by the plan?

If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan will cover your drugs as long as the drugs meet all of our rules for coverage. Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Formulary or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do. To be eligible for a temporary supply, you must meet the two requirements below: 

 1. The change to your drug coverage must be one of the following types of changes:
  • The drug you have been taking is no longer on the plan’s Formulary. -or-
  • The drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below:
  • For those members who were in the plan last year and aren’t in a long-term care facility: We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for up to 31-days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31-days of medication. You must fill the prescription at a network pharmacy.
  • For those members who are new to the plan and aren’t in a long-term care facility:
    We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for up to 31-days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 31-day of medication. You must fill the prescription at a network pharmacy.
  • For those members who were in the plan last year and are in a long-term care facility:  We will cover a temporary supply of your drug during the first 90 days of the calendar year. The total supply will be for up to 98-days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 98-day of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
  • For those members who are new to the plan and reside in a long-term care facility:
    We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The total supply will be for up to 98-days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 98-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.)
  • For those members who have been in the plan for more than 90 days and reside in a long-term care facility and need a supply right away:
    We will cover up to 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
If you are a current member with changes to your level of care, we will allow you to refill your prescription until we have provided you with a 31-day transition supply, consistent with the dispensing increment, unless you have a prescription written for fewer days. To ask for a temporary supply of a drug, call Member Services. Current members may also be affected by changes in our formulary from one year to the next. You should talk to your doctors to decide if you should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Chapter 6 of the IEHP DualChoice Member Handbook for information about non-Part D drugs.

IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. 

 
Information on this page is current as of October 15, 2018.
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