EmblemHealth’s goal is to make changes that occur each new benefit year as seamless as possible. EmblemHealth’s transition policy meets the immediate needs of our members and allows them time to work with their prescribing doctor to switch to another medication that is on the formulary to treat the member’s condition or ask for an exception.
Who is Eligible for a Temporary Supply?
During the first 90 days of membership, we offer a temporary supply of medications to:
- New members on January 1 following the Annual Election Period
- Newly eligible Medicare beneficiaries
- Existing members impacted by a negative formulary change from the prior year
- Members switching Medicare Part D plans after January 1
- Members residing in long-term care (LTC) facilities
- In some cases, enrollees who change treatment settings due to a change in level of care
Our transition policy applies to:
Part D medications that are not on EmblemHealth’s formulary and Part D medications that are on EmblemHealth’s formulary but may require:
- Prior authorization (PA) These are drugs that may or may not be included in our drug list that need to be approved in advance before we will cover it.
- Step therapy (ST) In these cases, we require your doctor to first try certain drugs to treat a medical condition before we will cover another drug.
- Quantity limitations (QL) These are drugs that we limit to a certain amount over a certain time period. If your doctor thinks you need to receive more, you can ask us for an exception.
Getting Medication from a Participating Network Pharmacy
For each medication that is not on our formulary or is subject to prior authorization, step therapy or quantity limits. EmblemHealth will cover a temporary one-time supply for at least a month's supply of medications (unless the prescription was written for fewer days) when you get it filled from a network pharmacy during the transition period. After the first month’s supply, you will need to request an exception for coverage, otherwise EmblemHealth will not pay for these medications, even if the member has been in the plan less than 90 days.
How is a Prescription Filled in Long-Term Care Facilities?
For members in long-term care facilities, prescription refills will be provided up to a month’s supply (unless the prescription was written for fewer days). We will cover more than one refill of these medications for the first 90 days as a member of our plan.
If a medication is needed that is not on our formulary or if the member’s ability to get medications is limited, but the member is past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that medication (unless a prescription was written for fewer days) while a formulary exception is requested.
How is a Member Notified about the Transition Supply?
All members (and their doctors) getting a temporary supply of a medication will be sent a letter about the member’s transition fill and the transition process. This letter will be sent within three business days of the temporary fill.
The notice will include:
- An explanation of the transition supply that the member received;
- How to work with EmblemHealth and the member’s prescriber to find another medication that is on the formulary to treat the member’s condition;
- An explanation of the member’s right to ask for a formulary exception; and
- A description of the formulary exception process.
What is the Copay for Temporary Medication?
The copay for the approved temporary medication will be based on one of our approved formulary tiers. The cost-sharing for a non-formulary drug provided during the transition period will be the same as the cost-sharing charged for non-formulary medications that are approved under a coverage exception. The cost share for formulary drugs that require prior authorization, step therapy or quantity limits approvals that are provided during the transition will be the same cost share after the prior approval criteria are met.
Copays for members who are eligible for “Extra Help” (a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance) during the transition period will never exceed the copay maximums set by the Centers for Medicare & Medicaid Services for low-income members.