Plan Transition Process
New Enrollees beginning January 1, 2009
(Non-Long-Term Care members)
RxAmerica recognizes, and will take into consideration, the specific needs of enrollees who require transition medication in their new Part D formulary, including but not limited to: members transitioning to RxAmerica from other prescription drug coverage, including other Part D plans, and whose current drug therapies may not be included in or consistent with RxAmerica formularies.
NON-FORMULARY DRUGS:
Members will receive a one time temporary 30-day fill (unless the member presents a prescription written for less than 30 days) for an ongoing prescription anytime during the first 90 days of enrollment in one of RxAmerica´s plans beginning on the member´s effective date of coverage. This is available at retail pharmacies only. The member cannot receive a first fill of non-formulary drugs through mail order. Members not receiving extra help from the government will be charged a co-pay at the non-formulary tier on our Advantage Freedom Plan or 25% coinsurance on our Advantage Star Plan. Those members receiving extra help will be charged a co pay that does not exceed the statutory maximum ($3.10 or $5.35, or 15% coinsurance) amount depending on their level of extra help.
The member will be notified two ways: (1) At point of sale the pharmacy will inform the member of the temporary fill, and (2) RxAmerica will send detailed written notification via U.S. Postal Service to the member within three days of receipt of a claim for a temporary fill, allowing members sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or time for the completion of a formulary exception request to maintain coverage of an existing drug based on medical necessity.
This process will apply to a new prescription for a non-formulary drug if the pharmacy cannot make the distinction between a new prescription and an ongoing prescription.
This process does not apply to Medicare Part D excluded drugs.
PRIOR AUTHORIZATION (PA)/STEP THERAPY DRUGS:
Members will receive a one time temporary 30-day fill (unless the member presents a prescription written for less than 30 days) for an ongoing prescription anytime during the first 90 days of enrollment in one of RxAmerica´s plans beginning on the member´s effective date of coverage. This is available at retail pharmacies only. The member cannot receive a first fill of PA/Step Therapy drugs through mail order. Members not receiving extra help from the government will be charged a co pay directly correlated to the formulary tiering on our Advantage Freedom Plan or 25% coinsurance on our Advantage Star Plan. Those members receiving extra help will be charged a co pay that does not exceed the statutory maximum ($3.10 or $5.35, or 15% coinsurance) amount depending on their level of extra help.
The member will be notified two ways: (1) At point of sale the pharmacy will inform the member of the temporary fill, and (2) RxAmerica will send detailed written notification via U.S. Postal Service to the member within three days of receipt of a claim for a temporary fill, allowing members sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or time for the completion of a prior authorization request to maintain coverage of an existing drug based on medical necessity.
This process will apply to a new prescription requiring a PA/Step Therapy drug if the pharmacy cannot make the distinction between a new prescription and an ongoing prescription.
This process does not apply to Medicare Part D excluded drugs.
QUANTITY LIMITS (INCLUDING DOSAGE):
RxAmerica has implemented quantity limits for safety purposes and drug utilization based upon approved product labeling. These safeguards may apply to non-formulary, PA/Step Therapy, and formulary drugs. During transition a pharmacy is allowed a one time override for an ongoing prescription for this safeguard if the prescriber will not authorize the change at point of sale, up to a 30 day supply only. Allowing the member to leave the pharmacy with a sufficient quantity of medication while the member works with the prescriber in making an appropriate switch or time to pursue an exception for medical necessity. This is available at retail pharmacies only; the member cannot receive a first fill for quantity limit overrides through mail order. Members not receiving extra help from the government will be charged a co pay directly correlated to the formulary tiering on our Advantage Freedom Plan or 25% coinsurance on our Advantage Star Plan. Those members receiving extra help will be charged a co pay that does not exceed the statutory maximum ($3.10 or $5.35, or 15% coinsurance) amount depending on their level of extra help.
The member will be notified two ways: (1) At point of sale the pharmacy will inform the member of the temporary quantity limit override, and (2) RxAmerica will send detailed written notification via U.S. Postal Service to the member within three days of receipt of a claim for a temporary override, allowing members sufficient time to work with the prescriber to make an appropriate switch or pursue an exception based on medical necessity.
This process will apply to a new prescription with quantity limits if the pharmacy cannot make the distinction between a new prescription and an ongoing prescription.
This process does not apply to Medicare Part D excluded drugs.
New Enrollees beginning January 1, 2007
(Long-Term Care members - LTC)
RxAmerica recognizes, and will take into consideration, the unique needs of residents in LTC facilities who require transition medication in their new Part D formulary, including but not limited to: members transitioning to RxAmerica from other prescription drug coverage, including other Part D plans via auto assignment or voluntary enrollment, and members whose current drug therapies may not be included in or consistent with RxAmerica formularies. RxAmerica also understands that Long Term Care members fluctuate in their level of care. Therefore, overrides for refill too soon will be given upon admission, discharge, or returning to the facility as well as for dosage changes by the prescriber before the regularly scheduled refill date.
NON-FORMULARY DRUGS:
Members will receive at least a 31-day increment fill (unless the member presents a prescription written for less than 31 days) for an ongoing prescription as necessary during the entire length of the 90 day transition period. These drugs must be dispensed to residents in a LTC facility. The transition period begins on the member´s effective date of coverage. Members not receiving extra help from the government will be charged a co pay at the non-formulary tier on our Advantage Freedom Plan or 25% coinsurance on our Advantage Star Plan. Those members receiving extra help will have a $0 co pay, per CMS guidelines.
However, if a LTC member is outside the 90-day transition period, an emergency supply may be provided in 31 day increments while an exception is being processed.
The member will be notified two ways: (1) At the point of sale the LTC pharmacy will notify the facility of the temporary fill, and (2) RxAmerica will send detailed written notification via U.S. Postal Service to the member within three days of receipt of a claim for a temporary fill, allowing members sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or time for the completion of a formulary exception request to maintain coverage of an existing drug based on medical necessity.
This process does not apply to Medicare Part D excluded drugs.
PRIOR AUTHORIZATION (PA)/STEP THERAPY DRUGS:
Members will receive at least a 31-day increment fill (unless the member presents a prescription written for less than 31 days) for an ongoing prescription as necessary during the entire length of the 90 day transition period. These drugs must be dispensed to residents at a LTC facility. The transition period begins on the member´s effective date of coverage. Members not receiving extra help from the government will be charged a co pay directly correlated to the formulary tiering on our Advantage Freedom Plan or 25% coinsurance on our Advantage Star Plan. Those members receiving extra help will have a $0 co pay, per CMS guidelines.
However, if a LTC member is outside the 90-day transition period, an emergency supply may be provided in 31 day increments while an exception is being processed.
The member will be notified two ways: (1) At the point of sale the LTC pharmacy will notify the facility of the temporary fill, and (2) RxAmerica will send detailed written notification via U.S. Postal Service to the member within three days of receipt of a claim for a temporary fill, allowing members sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or time for the completion of a formulary exception request to maintain coverage of an existing drug based on medical necessity.
This process does not apply to Medicare Part D excluded drugs.
QUANTITY LIMITS (INCLUDING DOSAGE):
RxAmerica has implemented quantity limits for safety purposes and drug utilization based upon approved product labeling. These safeguards may apply to non-formulary, PA/Step Therapy, and formulary drugs. During transition a LTC pharmacy is allowed to override for this safeguard if the prescriber will not authorize the change at point of sale, in 31 day supply increments only for an ongoing prescription as necessary during the entire length of the 90 day transition period. Allowing the member a sufficient quantity of medication while the member works with the prescriber in making an appropriate switch or time to pursue an exception for medical necessity. These drugs must be dispensed to residents at a LTC facility. Members not receiving extra help from the government will be charged a co pay directly correlated to the formulary tiering on our Advantage Freedom Plan or 25% coinsurance on our Advantage Star Plan. Those members receiving extra help have a $0 co pay, per CMS guidelines.
The member will be notified two ways: (1) At point of sale the LTC pharmacy will notify the facility of the temporary fill, and (2) RxAmerica will send detailed written notification via U.S. Postal Service to the member within three days of receipt of a claim for a temporary fill, allowing members sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or time for the completion of a formulary exception request to maintain coverage of an existing drug based on medical necessity.
This process does not apply to Medicare Part D excluded drugs.
