EmblemHealth Medicare Part D Transition Policy
EmblemHealth’s goal is to make changes that occur each new benefit year as seamless as possible. Our transition policy is designed to meet the immediate needs of our members and allow them time to work with their prescribing doctor to switch to another medicine that is on the formulary to treat the member’s condition, or to ask for an exception.
Who is eligible for a temporary supply?
During the first 90 days of membership, we offer a temporary supply of medicines to:
- New members on Jan. 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 Jan. 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 medicines that are not on EmblemHealth’s formulary and Part D medicines that are on EmblemHealth’s formulary but may require:
- Prior authorization (PA).
- Step therapy (ST).
- Quantity limits (QL).
Getting medicine from a participating network pharmacy
For each medicine 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 medicines (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 medicines, 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 during the first 90 days.
If a medicine is needed that is not on our formulary or if the member’s ability to get medicine 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 medicine, unless a prescription was written for fewer days, while a formulary exception is requested.
How is a member notified about the transition supply of their medicine?
All members getting a temporary supply of a medicine, and their doctors, 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 medicine supply that the member received.
- How to work with EmblemHealth and the member’s prescriber to find another medicine that is on the formulary to treat the member’s condition.
- An explanation of the member’s right to ask for a formulary exception.
- A description of the formulary exception process.
What is the copay for temporary medicine?
The copay for the approved temporary medicine 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 medicines 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 during the transition period will never exceed the copay maximums set by the Centers for Medicare & Medicaid Services (CMS) for low-income members.
