Health First Medicare Plans - Prescription Transition Policy (2008)

What if I’m taking a drug that isn’t on the formulary or needs authorization, but I need it before I can change or get approval?

While you talk to your doctor about changing to a covered drug or requesting approval, we will cover a temporary supply of eligible medications according to the following transition policy guidelines:

Eligible medications are those that:

1. are covered under Medicare Part D that are not on our formulary, or are on our formulary with prior authorization or step therapy requirements, and
2. are obtained from a network pharmacy.

• New members (within 90 days of initial enrollment) — We will cover up to a 30-day supply of the eligible medications that were prescribed to you before you enrolled in our plan. After your first temporary supply, no further refills will be covered unless an exception is approved. More information about the exceptions process
• Members living in long-term care facilities — We will cover up to a 31-day supply of eligible medications, even if they are prescribed after you enrolled in our plan. If you are a new member (within 90 days of initial enrollment), we will also cover more than one refill during the first 90 days of your membership. If you have been enrolled in our plan for more than 90 days, refills of non-covered medications will not be covered after the first temporary supply.

• Members who were enrolled in a Health First Medicare Plan as of December 31, 2007

  • If your drug was removed from the formulary as of January 1, 2008 — If you are taking a medication that was no longer covered on January 1, 2008,   we will cover up to a 30-day supply of your medication through the end of March 2008 while you transition to a covered alternative or pursue an exception. After your first temporary supply, no further refills will be covered unless an exception is approved. More information about the exceptions process
  • If your formulary exception was not honored as of January 1, 2008 — If your formulary exception expired on December 31, 2007,   we will cover up to a 30-day supply of your medication through the end of March 2008 while you transition to a covered medication or pursue an exception. After your first temporary supply, no further refills will be covered unless an exception is approved. More information about the exceptions process
• Members who change treatment settings (i.e. hospital to home) — We will cover up to a 30-day supply of eligible medications if you have been prescribed a non-covered drug as a result of changing from one treatment setting to another. An example of a change in treatment setting is being discharged from a hospital or a skilled nursing facility to return home.

Note: Your cost for transition supplies will be the highest drug cost-share under your plan. Exceptions cannot be made for the cost of these medications.

The temporary transition supplies are provided in order to give you to time to talk to your doctor about switching to an appropriate formulary drug or requesting a formulary exception. If you have any questions about this policy, please contact our Customer Service Department at (321) 434-5665 or (800) 716-7737 8 am-8 pm any day of the week. TTY/TDD users should call the Florida Relay Center at 1-800-955-8771 during the same hours.

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Last updated: 10/16/2007