Transition Supply Process

What if my current prescription drugs are not on the formulary or are limited on the formulary?

Under certain circumstances, IBC can offer a temporary transition supply of a drug to you when your drug is not on the Drug Formulary or when it is restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and figure out what to do.

For New Members

As a new member in our plan, you might currently be taking a drug that is not on our formulary. Or, the drug is on our formulary but your ability to get it is limited. In instances like these, you should 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-day transition supply of the drug anytime during the first 90 days if 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. If there are none, you or your doctor may 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 if 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.

For Continuing Members

If you already are a member in the plan, you should have received your Annual Notice of Change/Evidence of Coverage (ANOC/EOC) by September 30. You may notice that a formulary medication that you are currently taking is either not on the upcoming year’s formulary or its cost-sharing or that coverage is limited in the upcoming year.

You may currently be taking drugs that in 2012 may require prior authorizations (approval in advance), and/or have quantity limit restrictions. In instances like this, you need to talk with your doctor about appropriate alternative therapies available on our formulary. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if 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 supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you have any questions about our transition policy or need help asking for a formulary exception, call Customer Service at the number printed on the back of your ID card.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
• Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.”

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.

Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.

Y0041_HM_12_300a Pending CMS Approval