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ConnectiCare’s goal is to make changes that occur each new benefit year as seamless as possible. Our transition policy meets the immediate needs of our members and allows them time to work with their prescribing doctor to switch to another medication that is on the covered drug list (formulary) to treat their conditions or ask for an exception.
Who is eligible for a temporary supply?
During the first 90 days of membership, we offer a temporary supply of medications to:
- New members on January 1 following the Annual Enrollment Period
- Newly eligible Medicare beneficiaries
- Existing members impacted by a negative formulary change from the prior year
- Members switching Medicare Part D plans after January 1
- Members residing in long-term care (LTC) facilities
- In some cases, enrollees who change treatment settings due to a change in level of care
Our transition policy applies to Part D drugs that are not on our formulary and Part D drugs included in our formulary, but may require:
- Prior authorization (PA): These are drugs that may or may not be included in our drug list that need to be approved in advance before we will cover it.
- Step therapy (ST): In these cases, we require your doctor to first try certain drugs to treat a medical condition before we will cover another drug.
- Quantity limitations (QL): These are drugs that we limit to a certain amount over a certain time period. If your doctor thinks you need to receive more, you can ask us for an exception.
Getting medication from a participating network pharmacy
For each medication that is not on our formulary or is subject to prior authorization, step therapy or quantity limits, ConectiCare will cover a temporary one month supply of medications (unless the prescription was written for fewer days) when you get it filled from a network pharmacy during the transition period. After the first one month supply, you will need to request an exception for coverage, otherwise we will not pay for these medications, even if the member has been in the plan less than 90 days.
How is a prescription filled in long-term care facilities?
For members in long-term care facilities prescription refills will be provided up to a month’s supply (unless the prescription was written for fewer days). We will cover more than one refill of these medications for the first 90 days as a member of our plan.
If a medication is needed that is not on our formulary or if the member’s ability to get medications is limited, but the member is past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that medication (unless a prescription was written for fewer days) while a formulary exception is requested.
How is a member notified about the transition supply?
All members (and their doctors) getting a temporary supply of a medication will be sent a letter about the member’s transition fill and the transition process. This letter will be sent within three business days of the temporary fill.
The notice will include:
- An explanation of the transition supply that the member received;
- How to work with us and the member's prescriber to find another medication that is on the formulary to treat the member’s condition;
- An explanation of the member’s right to ask for a formulary exception; and
- A description of the formulary exception process.
What is the copay for temporary medication?
The copay for the approved temporary medication will be based on one of our approved formulary tiers. The cost share for a non-formulary drug provided during the transition period will be the same as the cost share charged for non-formulary medications that are approved under a coverage exception. The cost share for formulary drugs that require prior authorization, step therapy or quantity limits approvals that are provided during the transition will be the same cost share after the prior approval criteria are met.
Copays for members who are eligible for “Extra Help” (a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance) during the transition period, will never exceed the copay maximums set by the Centers for Medicare & Medicaid Services for low-income members.
Medication Therapy Management MTM
The MTM Program is a free service for EmblemHealth Medicare plan members with Part D prescription drug coverage who have certain health conditions and who take a certain number of chronic medications.
As part of our commitment to patient safety, we have taken steps to ensure that prescription drugs are used safely and effectively by our Medicare Part D members. Members can be at risk for drug errors and drug-related problems since they often get prescriptions from more than one doctor. We make sure drugs are used safely by:
- Screening for drug interaction: Using prescription-tracking software, we automatically screen member’s drug profile for possible harmful interactions with other drugs the member may be taking.
- Making sure medications are right for your age group: We check if a drug has a warning for certain age groups. We’ve added drugs to our formulary that are safe for older members and removed those that are not as safe. We also educate our doctors about their prescribing patterns and about drugs that may not be right for older patients.
- Ensuring dosages are safe: To prevent possible overdose, we review each member’s drug profile to determine if a drug is being prescribed following FDA dosing guidelines.
- Avoiding drug duplication: We also screen each member’s drug profile to determine if the same or similar drug already exists in themember's drug profile.
- Send pharmacy reports to doctors: We review each member’s drug profile to determine if he/she is being prescribed more medications than he/she needs. This report is shared with prescribing doctors. The doctor then decides on the right therapy, if needed.
If you have any questions about our medication safety programs, call us at 800-224-2273 (TTY: 711) from 8 a.m. to 8 p.m., seven days a week.
ConnectiCare Pharmacy Benefit Services completes quality assurance reviews of the medicines our members take to avoid medication errors, harmful drug interactions and improve medication use. We also oversee the use of prescription drugs and check each prescription filled based on these criteria:
- Dosing: We make sure each drug you take is within established dosage ranges, meaning not too high or too low.
- Gender/age: We check to see if a prescribed drug is right for member’s gender and age.
- Proper Medication Use: We look at the time frame for refills and new fills. We do this to make sure that members take their prescribed drugs as directed and follow established dosing guidelines for controlled and non-controlled substances.
- Drug-to-Drug; Drug-to-Disease interaction: We look at medication profiles to find any potential interactions between prescribed drugs and a member’s health conditions.
- Medication duplication: We screen each member profile to make sure that newly prescribed drugs are not the same as other drugs the member is taking.
- FDA-issued warnings: We review FDA-issued warnings about any harmful reactions to medications, new dosage formulations and how the drug is administered (orally, injectable, topically, etc.). We re-evaluate the formulary (list of covered drugs) to make improvements based on our reviews.
If you have any questions or concerns, please call us at 800-224-2273 (TTY: 711) from 8 a.m. to 8 p.m. seven days a week.
Medicare provides "Extra Help" to pay for prescription drug costs for people who have limited income and resources. If you qualify, you will receive help paying for your drug copays. ConnectiCare accepts several forms of evidence to establish your eligibility to receive help to lower your cost for your prescription drugs. That evidence may be provided by the beneficiary or the beneficiary’s pharmacist, advocate, representative, family member or other individual acting on behalf of the beneficiary. For more information, please view the best available evidence policy (BAE). Learn more about this policy.
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Last update 10/01/2023
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