Prescription Drug Transition Policy

What can you do if a drug you are taking is not on the List of Drugs? What if the drug is restricted in some way? If your drug is not on the List of Drugs or is restricted, here are things you can do:

  • You may be able to get a temporary supply of the drug. Only members in certain situations can get a temporary supply.
  • You can change to another drug.
  • You can ask for an exception and ask Absolute Total Care to cover the drug.

Under certain circumstances, Absolute Total Care can offer a temporary supply of a drug to you when your drug is not on the List of Covered Drugs or when it is restricted in some way. This temporary supply allows you time to talk to your doctor about a different medication which is on the drug list or different dose which is covered.

To be eligible for a temporary supply, you must meet BOTH of the two requirements below:

1.    The drug you have been taking:

  • Is no longer on Absolute Total Care’s drug list OR
  • Was never on Absolute Total Care’s drug list OR
  • Is now restricted in some way.

AND

2.     You must be in one of the situations described below:

  • You were in the plan last year and do not live in a long-term care facility.
    • We will cover a short-term supply of your drug for the first 90 days of the calendar year. This short-term supply will be for up to a 30-day supply. Your doctor may not let you have the whole 30-day supply at one time. We will allow multiple fills of the drug up to a maximum of a 30-day supply.
    • You must get your drugs at a network pharmacy.
  • You are new to the plan and do not live in a long-term care facility.
    • We will cover a short-term supply of your drug for up to 180 days on the plan. This short-term supply will be for up to a 30-day supply. Your doctor may not let you have the whole 30-day supply at one time. We will allow multiple fills of the drug up to a maximum of a 30-day supply.
    • You must get your drugs at a network pharmacy.
  • You were in the plan last year and live in a long-term care facility
    • We will cover a short-term supply of your drug for the first 90 days of the calendar year. The total supply will be for up to a 91- to 98-day supply. This will depend on the amount provided with each fill. We will fill the drug to allow up to a maximum of 91- to 98-days if provided in smaller amounts. This may be done to avoid waste.
  • You are new to the plan and live in a long-term care facility.
    • We will cover a short-term supply of your drug for the first 180 days on the plan. The total supply will be for up to a 91- to 98-day supply. This will depend on the amount provided with each fill. We will fill the drug to allow up to a maximum of 91- to 98-days if provided in smaller amounts. This may be done to avoid waste.

For those who have been a member of Absolute Total Care for more than 90 days, are a resident of a long-term care facility, and need a supply right away:

We will cover one 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. An exception or prior authorization should also be requested at the time the prescription is filled.

Absolute Total Care will cover a 31-day short supply for Part D covered drugs if a member:

  • Is discharged from a hospital or skilled-nursing facility to a home setting.
  • Is admitted to a hospital or skilled-nursing facility from a home setting.
  • Transfers from one skilled-nursing facility to another and are served by a different pharmacy.
  • Ends their skilled-nursing facility stay (where payments include all pharmacy charges) and who now need to use their plan benefit.
  • Members who give up Hospice Status and go back to standard and coverage Medicare Part A and B coverage.
  • Is discharged from psychiatric hospitals with highly individualized drug regimens.

You must fill your prescription at a network pharmacy. If you change treatment settings more than once in the same month, you may have to get approval for continued coverage of your drug.  We will review requests as needed. We understand that changes can cause risks. Call Member Services to ask for a temporary (short-term) supply.

The cost-sharing for a short supply will not go above what is the legal amount for low-income subsidy (LIS) eligible enrollees.

After you get your Transition Fill

After you get your short-term supply you will get a letter. The letter will be sent in three days. It will tell you what to do next. 

Your doctor will also get a copy of the letter.

Talk with your doctor. You can decide what to do when the supply runs out. Here are your choices:

You can change to another drug:

There may be a different drug covered that will work for you.

Call Member Services to ask for a list of covered drugs used for the same condition. The list can help your doctor find a covered drug that might work for you.

OR

You can ask for an exception:

You or your doctor can ask to make an exception. You can ask to cover a drug that is not on the List of Drugs. You can ask to cover the drug without limits. To request an exception, your doctor can call 1-844-202-6824 (TTY: 711) or your doctor can fax the Drug Coverage Determination Form to 1-877-941-0480. 

Contact Member Services for help to request an exception. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

When we get the request from your doctor, we must tell you what we decide in 72 hours. If it is a fast request, we must tell you what we decide in 24 hours.


OR

You can fill out and send us a Drug Coverage Determination Form:

Drug Coverage Determination Form

You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins - except prenatal vitamins and fluoride preparations.

If you have any questions, call Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

Last Updated: 09/30/2017
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