Additional Resources: Medicare Part D Transition Policy Overview
We want to make the transition into the new benefit year for Medicare Part D members as seamless as possible. That's why we have policies in place for any prescription drugs that you may be taking. During the first 90 days of membership, we offer a temporary supply of medications to Medicare Part D members who:
- Are taking a medication that is not on the formulary or
- Are taking a medication that is subject to certain restrictions such as prior approval, quantity limits or step therapy, depending on place of service.
ConnectiCare will offer a temporary one-time fill for a non-formulary drug. The copay will be based on one of our approved formulary tiers. It will also be consistent with cost-sharing charged for non-formulary drugs that are approved under a coverage exception. Copays for members who are eligible for "extra help" will never exceed the copay maximums set by the Centers for Medicare & Medicaid Services for low-income members.
If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year when you use a participating pharmacy or during the first 90 days of the new plan year for long-term care facility residents.
What are the details of the participating pharmacy policy?
Provided that the drug is dispensed from a participating pharmacy, ConnectiCare will offer a one-time fill of up to a 30-day supply of a drug, if:
- The drug is not a formulary drug.
- The drug requires prior approval.
- The drug does not meet the required step therapy edits.
- The drug is subject to a quantity limit.
Who is eligible?
Newly eligible Medicare Part D participants or those enrolling from another plan during their first 90 days of membership.
What are the details of the long-term care (LTC) facility transition policy?
Provided that the drug is dispensed from a participating pharmacy, qualified long-term care facility residents will be provided multiple fills of a 31-day supply up to a 98-day supply during the 90-day LTC transition window, if:
- The drug is not a formulary drug.
- The drug requires prior approval.
- The drug does not meet the required step therapy edits.
- The drug is subject to a quantity limit.
If the prescription is written for fewer days and has applicable refills, it will be approved.
Who is eligible?
Newly eligible Medicare Part D participants or those enrolling from another plan, or current enrollees for medications utilized by the current enrollees in the previous plan year if that medication has also had a negative formulary change across years during their first 90 days of membership.
H3528_13_4006_01 CMS Approved 11/09/2012
Last Update 10/1/2012
