Commonwealth Care Alliance

Senior Care Options Program (HMO SNP)

Pharmacy » Prescription Coverage » Plan Transition

Plan Transition

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List 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 Drug List.
  • — 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 are new or who were in the plan last year and aren’t in a long-term care (LTC) facility:
    • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year.
    • This temporary supply will be for a maximum of 30- day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply of medication. The prescription must be filled at a network pharmacy.
  • For those members who are new or who were in the plan last year and reside in a
    long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are new and during the first 90 days the calendar
    year if you were in the plan last year. The total supply will be for a maximum of a 98- day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 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 (LTC) facility and need a supply right away:
    We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
  • For those who have a level of care transition:
    For current enrollees with level-of-care changes, we will provide an emergency supply of at least 31-days (unless the prescription is written for fewer days) for all non-formulary medications including those that may have step therapy or prior authorization requirements.
    An unplanned level of care transition could be any of the following:

    • a discharge or admission to a Long Term Care facility
    • a discharge or admission to a hospital, or
    • a nursing facility skilled level change

To ask for a temporary supply, call Member Services at 1-866-610-2273 (TYY 711).

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To find out what drugs are covered by our plan, please review the List of Covered Drugs. To request an exception, please go to Request Exception to Formulary. If you have any questions or need help, please call Member Services at 1-866-610-2273 (TTY: 711).

Please review Chapter 5, Section 5 of the Evidence of Coverage (Member Handbook) for detail information about your options and transition supply.

 

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Commonwealth Care Alliance website pages.) Click here for more information about Adobe Acrobat.

*When you click this link, you will leave Commonwealth Care Alliance’s website.

Last Updated 06/21/2016