ApexHealth wants to make getting Medicare Part D prescription drug coverage for the treatment you need as simple as possible. This policy applies to new members taking a medication that is either not covered or is covered but contains utilization management controls, members entering/discharging from a long-term care facility, and current members who are impacted by a formulary change across contract years. This policy allows a transition period in which ApexHealth will cover a temporary supply of medication to ensure members complete a successful
transition and avoid disruption in treatment.
The transition policy provides at least a 30 days’ supply of medication, anytime during the first 90 days of your enrollment in the plan, beginning on your effective date of coverage. We encourage members to talk with their doctors to decide if they should switch to a different drug that is covered or to request a formulary exception
to get coverage for the drug.
After the transition period has expired or the days-supply is exhausted, the transition policy will provide members living in a long-term care facility at least a 31-day emergency supply of non-formulary Part D drugs (unless the prescription is written for less than 31 days) while an exception or prior authorization determination is pending. For members being admitted to, or discharged from, a long-term care facility, the early refill edits will not be used to limit appropriate and necessary access to their Part D benefit, and such enrollees will be allowed to access a refill upon admission or discharge.
We will provide you with written notice within three business days of your temporary transition supply that will include instructions for requesting a formulary exception and how to work with your doctor to decide if you should switch to an appropriate drug we cover. Your doctor will receive a copy of this notice as well.
The transition policy applies to Part D drugs that:
- Are not on our formulary; and
- Are on our formulary but require prior authorization or step therapy, or that
- have approved quantity limits lower than your current dose, under our
- utilization management rules.
All prescriptions must be filled at an in-network pharmacy.