What if my current prescription drugs are not
on the formulary or are limited on the formulary?
New Members
As a new member in our plan, you may currently be taking drugs that are not on our
formulary or are on our formulary but your ability to get them is limited. In instances
like these, you need to talk with your doctor about appropriate alternative therapies
available on our formulary. If there are no appropriate alternative therapies on
our formulary, you or your doctor can request a formulary exception. If the exception
is approved, you will be able to obtain the drug you are taking for a specified
period of time. While you are talking with your doctor to determine your course
of action, you may be eligible to receive an initial 30 days transition supply of
the drug anytime during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or for situations where your
ability to get your drugs is limited, we will cover a temporary 30-day supply (unless
you have a prescription written for fewer days) when you go to a network pharmacy.
After your first 30-day transition supply, we may not continue to pay for these
drugs under the transition policy. You are reminded to discuss with your doctor
appropriate alternative therapies on our formulary and if there are none, you or
your doctor can request a formulary exception.
If you are a resident of a long-term care facility, we will cover a temporary 31-day
transition supply (unless you have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first 90 days you are a member
of our plan. If you need a drug that is not on our formulary or your ability to
get your drugs is limited, but you are past the first 90 days of membership in our
plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription
for fewer days) while you pursue a formulary exception.
Continuing Members
As a continuing member in the plan, you will receive your Annual Notice Of Change
(ANOC) by October 31st. You may notice that a formulary medication which you are
currently taking is either not on the upcoming year’s formulary or its cost sharing
or coverage is limited in the upcoming year. In this case, we will provide for a
transition period consistent with the above transition process for new enrollees.
Due to a change in Medicare Regulations, most Medicare Drug Plans including Central
Health Medicare Plan will no longer cover erectile dysfunction (ED) drugs like Viagra,
Cialis, Levitra, and Caverject.
Current Members with a change in their level
of care
Central Health Medicare Plan acknowledges that you may experience a change in the
level of care you receive and/or may be required to transition from one facility
or treatment site to another. Exceptions are available to you if you experience
a change in the level of care you are receiving. Examples of when you would be eligible
for a one-time temporary fill exception for changes in your level of care are:
- You have been discharged from the hospital and have been provided a discharge list
of medications based upon the formulary of the hospital;
- Your have completed your Part A stay at a skilled nursing facility (where payments
included all pharmacy charges) and have reverted back to your Part D plan formulary;
- You have discontinued Hospice Status and have reverted back to standard Medicare
Part A and B benefits; or
- You have been discharged from a Chronic Psychiatric Hospital with a medication regimen
that is highly individualized.
If you experience a change in the level of care you are receiving, Central Health
Medicare Plan will cover a temporary 30-day supply (unless you have a prescription
written for fewer days) regardless of whether or not you are not within your first
ninety (90) days of program enrollment.
If you have any questions about our transition policy or need help asking for a
formulary exception, call Member Services at 1-866-314-2427 or TTY/TDD 1-888-205-7671.