Transition Policy

Elderplan Part D Transition Process

As a new or continuing member in Elderplan, you may be taking drugs that are not on our Drug List (formulary) or that are subject to certain restrictions, such as prior authorization or step therapy. You should talk with your doctor to decide if the alternative drug on our Drug List is right for you or request an exception: Prescription Drug Determination Claim Form (which is a type of coverage determination) in order to get coverage for the drug. See Section 6 of Evidence of Coverage (under “What is an exception?”) to learn more about how to request an exception. You can also contact our Member Services listed below.

You may be able to get a temporary supply (transition fill or supply)

Under certain circumstances, Elderplan can offer a temporary 30-day supply (unless prescription is written for less) of a drug that is not on our Drug List or requires prior authorization or step therapy.
During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by our plan that is right for you. Or you and your doctor can ask for an exception. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again.
The co-pay for a temporary supply will be based on one of our approved formulary tiers. It will also be consistent with cost-sharing charged for drugs that are approved under a coverage exception. Co-pays for members who are eligible for “Extra Help” will never exceed the co-pay maximums set by CMS for low-income members.
Please note that our transition policy applies only to those drugs that are “Part D drugs” and that are 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.
For any additional information on the formulary exception or transition process, please call Member Services at 1-800-353-3765, 8 a.m. to 8 p.m., 7 days a week. TTY users call 711.

Transition Notice

Elderplan will send you a written notice within three business days of the transition fill explaining the following:

That the transition supply is temporary and may not be refilled unless a formulary exception is requested and approved
How to work with Elderplan and your doctor to identify appropriate alternative drugs on the Drug List
Your right to request a formulary exception, the timeframes for handling an exception and your right to request an appeal
Procedures for requesting a formulary exception

Who is Eligible?

New Elderplan Members

As a new member in Elderplan, you may currently be taking drugs that are not on the Elderplan formulary or are on the formulary but require prior authorization or step therapy (requirement to try a different drug first). Anytime during the first 90 days you are a member, you may be eligible to receive a 30-day transition supply of each drug you are taking when you go to a network pharmacy.
If you get a 30-day transition supply, you should talk with your doctor to decide if you should switch to an appropriate alternative drug that is covered on the formulary. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again.
If no appropriate alternative drugs are on the formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to get the drug you are taking for a specified period of time.
If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will allow a refill of a prescription until we have provided 91 and maybe up to a 98-day transition supply, consistent with the dispensing increment (unless the prescription is written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of Elderplan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in Elderplan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Current Elderplan Members

As a continuing member in our plan from year to year, you will receive an Annual Notice of Change (ANOC) by October 1. You may notice that a formulary drug you currently take will not be on the new formulary, the drug’s cost sharing will change, or the drug requires prior authorization or step therapy in the upcoming year. If this happens, you should talk with your doctor to decide if you should switch to an appropriate alternative drug that is covered on our formulary. We will provide you with the opportunity to request a formulary exception in advance for the following year.
If no appropriate alternative drugs are on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time.
If you are still within the first 90 days of your membership, you may be eligible to receive an initial 30-day transition supply of the drug.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91 and maybe up to 98-day transition supply, consistent with dispensing increment. We will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of Elderplan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in Elderplan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Current Elderplan Members who enter a long-term care (LTC) facility (level of care change)

If you enter a long-term care (LTC) facility from the outpatient (home), hospital or another LTC facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days after you have entered the LTC facility.
If you leave the LTC facility or a hospital and return to the outpatient setting, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) within the first seven days following the discharge when you go to a network pharmacy, for each of the drugs that is not on our Drug List or that has coverage restrictions or limits (and the drug is otherwise a “Part D drug”). After the first 30-day supply, we will not pay for these drugs. We will allow a refill of a prescription until we have provided 91 and maybe up to a 98-day transition supply, consistent with the dispensing increment (unless the prescription is written for fewer days).