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Drug Transition Policy

What can you do if a drug you are taking is not on the List of Drugs? What if the drug is restricted in some way? If your drug is not on the List of Drugs or is restricted, here are things you can do:

  • You may be able to get a temporary supply of the drug. Only members in certain situations can get a temporary supply. A temporary supply is a short term supply of drugs that gives you time to talk with your doctor about getting a different drug. It gives you time to ask the plan to cover the drug.
  • You can change to another drug.
  • You can ask for an exception and ask IlliniCare Health to cover the drug.

To be eligible for a temporary supply, you must meet BOTH of the two rules below:

1.     The drug you have been taking:

  • Is no longer on IlliniCare Health’s Drug List OR
  • Was never on IlliniCare Health’s Drug List OR
  • Is now limited in some way

2.     AND You must be in one of the situations listed below:

  • You were in the plan last year and do not live in a long term care facility.
    • We will cover a short term supply of your drug for the first 90 days of the calendar year. This short term supply will be for up to a 30-day supply. Your doctor may not let you have the whole 30-day supply at one time. We will allow multiple fills of the drug up to a maximum of a 30-day supply.
    • You must get your drugs at a network pharmacy.
  • You are new to the plan and do not live in a long term care facility.
    • We will cover a short term supply of your drug for the first 90 days on the plan. This short term supply will be for up to a 30-day supply. Your doctor may not let you have the whole 30-day supply at one time. We will allow multiple fills of the drug up to a maximum of a 30-day supply.
  • You were in the plan last year and live in a long-term care facility
    • We will cover a short term supply of your drug for the first 90 days of the calendar year.  The total supply will be for up to a 91- to 98-day supply. This will depend on the amount provided with each fill. We will fill the drug to allow up to a maximum of 91- to 98-days if dispensed in smaller amounts. This may be done to avoid waste.
  • You are new to the plan and live in a long term care facility.
    • We will cover a short term supply of your drug for the first 90 days on the plan. The total supply will be for up to a 91- to 98-day supply. This will depend on the amount provided with each fill. We will fill the drug to allow up to a maximum of 91- to 98-days if dispensed in smaller amounts. This may be done to avoid waste.
    • You must get your drugs at a network pharmacy.
  • You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away.
    • We will cover one 31-day supply. We will cover less than a 31-day supply if the amount your doctor prescribed was for fewer days.  This is in addition to the above long-term care transition supply.

During the plan year you may have a change in the place where you get and take your medicine.  This change is due to the level of care you need. IlliniCare Health will cover up to a 31-day short term supply for Part D covered drugs if a member:

  • Is discharged from a hospital or skilled-nursing facility to a home setting
  • Is admitted to a hospital or skilled-nursing facility from a home setting
  • Transfers from one skilled-nursing facility to another and are served by a different pharmacy
  • Ends their skilled-nursing facility stay (where payments include all pharmacy charges) and who now need to use their plan benefit
  • Gives up Hospice Status and goes back to standard coverage
  • Is discharged from psychiatric hospitals with highly individualized drug regimens

You must fill your prescription at a network pharmacy. If you change treatment settings more than once in the same month, you may have to get approval for continued coverage of your drug.  We will review requests as needed. We understand that changes can cause risks. Call Member Services to ask for a temporary (short) supply.

The cost-sharing for a short supply will not go above what is the legal amount for low-income subsidy (LIS) eligible enrollees.

After you get your Transition Fill

After you get your short supply you will get a letter. The letter will be sent in 3 days. It will tell you what to do next. 

Your doctor will also get a copy of the letter.

Talk with your doctor. You can decide what to do when the supply runs out. Here are your choices:

You can change to another drug:

There may be a different drug covered that will work for you.

Call Member Services to ask for a list of covered drugs used for the same condition. The list can help your doctor find a covered drug that might work for you.

OR

You can ask for an exception:

You or your doctor can ask us to make an exception. You can ask to cover a drug that is not on the Drug List. You can ask to cover the drug without limits.  To request an exception, your doctor can call 1-866-399-0928 (TTY: 711), or your doctor can fax the drug coverage determination form to 1-877-941-0480.  Contact 1-877-941-0482 (TTY: 711) for help to request an exception. 

When we get the request from your doctor, we must tell you what we decide in 72 hours. If it is an expedited (fast) request, we must tell you what we decide in 24 hours.

If you have questions, please call 1-877-941-0482. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and holidays, you may leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free.

 

Last Updated: 02/08/2018
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